Basic Information
| Provider Information | |||||||||
| NPI: | 1295785822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 E PARRISH AVE | ||||||||
| Address2: | STE 460 | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423033222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706845005 | ||||||||
| FaxNumber: | 2709264432 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 E PARRISH AVE | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423033258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706845005 | ||||||||
| FaxNumber: | 2709264432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01044112A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 01044112A | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000067774 | 01 | IN | BLUE SHIELD | OTHER | 000000683152 | 01 | ANTHEM | OTHER | 0360915761 | 05 | IL | MEDICAID | 050040838 | 01 | RAILROAD MEDICARE | OTHER | 200047560 | 05 | IN | MEDICAID |