Basic Information
| Provider Information | |||||||||
| NPI: | 1790786408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1351 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728111351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002351415 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1808 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728012724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799682841 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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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 | 207L00000X | C7989 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 050031807 | 01 | RR MEDICARE GROUP CC5970 | OTHER | 770078201 | 01 | AR | AR BREASTCARE | OTHER | 125265001 | 05 | AR | MEDICAID | 5J371 | 01 | AR | BLUE CROSS BLUE SHIELD AR | OTHER |