Basic Information
Provider Information | |||||||||
NPI: | 1578547584 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REEVE | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | III | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 157 CLINIC AVE | ||||||||
Address2: | SUITE 302 | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301174413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708343336 | ||||||||
FaxNumber: | 7708322136 | ||||||||
Practice Location | |||||||||
Address1: | 157 CLINIC AVE | ||||||||
Address2: | SUITE 302 | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301174413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708343336 | ||||||||
FaxNumber: | 7708322136 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 29759 | GA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 00344539A | 05 | GA |   | MEDICAID | 271249 | 01 | GA | BLUE CROSS | OTHER | 30117A003 | 01 | GA | CHAMPUS | OTHER | AETNA | 01 | GA | 5417058 | OTHER |