Basic Information
| Provider Information | |||||||||
| NPI: | 1659477560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4567 CROSSROADS PARK DR | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152952100 | ||||||||
| FaxNumber: | 3152952125 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 W GENESEE ST | ||||||||
| Address2: | STE 124 | ||||||||
| City: | CAMILLUS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130313200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154728841 | ||||||||
| FaxNumber: | 3154728859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2014 | ||||||||
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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 | 2084N0400X | 166445 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 01037663 | 05 | NY | MEDICAID |