Basic Information
| Provider Information | |||||||||
| NPI: | 1659367449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | WILLARD | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 530 CORPORATE CIR | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281478074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046370158 | ||||||||
| FaxNumber: | 7046377710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 04/17/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 17741 | NC | N | Other Service Providers | Specialist | 207Y00000X | 17741 | NC | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 02606 | 01 | NC | BCBS PROVIDER ID | OTHER | 4412228 | 01 | NC | AETNA | OTHER | 30158896 | 01 | SC | SELECT HEALTH OF SC | OTHER | P01259200 | 01 | NC | RAILROAD MEDICARE | OTHER | Q17741 | 05 | SC | MEDICAID | 83198 | 01 | NC | BCBSNC | OTHER | 8902606 | 05 | NC | MEDICAID |