Basic Information
| Provider Information | |||||||||
| NPI: | 1336256486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAVLATOS | ||||||||
| FirstName: | THALES | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 632621 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452632621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066500705 | ||||||||
| FaxNumber: | 7066501034 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455021312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375213900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 02/25/2013 | ||||||||
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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 | 35051485P | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 35051485 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0598698 | 05 | OH | MEDICAID |