Basic Information
| Provider Information | |||||||||
| NPI: | 1568417772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THORSTAD | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Practice Location | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
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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 | 2085R0202X | MD25159 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | 25159 | TN | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0204X | 25159 | TN | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3102002 | 01 | TN | BCBS | OTHER | 1509319 | 01 | TN | MEDICAID - MTI | OTHER | 1509319 | 05 | TN | MEDICAID | 4201075 | 01 | TN | BCBS TN | OTHER | 2644117 | 01 | TN | CIGNA | OTHER | 300106387 | 01 | TN | RAILROAD MEDICARE | OTHER | 4291298 | 01 | TN | BCBS - MTI | OTHER | 64917941 | 01 | KY | KY MEDICAID | OTHER | 1600684 | 01 | TN | UNITED HEALTHCARE OF TN | OTHER | 3135871 | 01 | TN | BCBS | OTHER | 64917941 | 05 | KY | MEDICAID | 3080836 | 05 | TN | MEDICAID | 4076947 | 01 | TN | BCBS | OTHER |