Basic Information
| Provider Information | |||||||||
| NPI: | 1497726376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RENFRO | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 FRONT ST W | ||||||||
| Address2: | |||||||||
| City: | COEBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242303607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763952389 | ||||||||
| FaxNumber: | 2763956634 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 FRONT ST W | ||||||||
| Address2: | |||||||||
| City: | COEBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242303607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763952389 | ||||||||
| FaxNumber: | 2763956634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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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 | 207R00000X | 0101039754 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1497726376 | 05 | VA | MEDICAID | 6466581300 | 05 | KY | MEDICAID |