Basic Information
Provider Information | |||||||||
NPI: | 1922099365 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMSON | ||||||||
FirstName: | ROY | ||||||||
MiddleName: | VARGHESE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX CVPI | ||||||||
Address2: |   | ||||||||
City: | RICHLANDS | ||||||||
State: | VA | ||||||||
PostalCode: | 24641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2769646771 | ||||||||
FaxNumber: | 2769641206 | ||||||||
Practice Location | |||||||||
Address1: | ONE CLINIC DRIVE | ||||||||
Address2: | CLAYPOOL HILL | ||||||||
City: | RICHLANDS | ||||||||
State: | VA | ||||||||
PostalCode: | 246411100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2769646771 | ||||||||
FaxNumber: | 2769641206 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2005 | ||||||||
LastUpdateDate: | 03/10/2010 | ||||||||
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 | 208000000X | 0101048293 | VA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 036643 | 01 |   | ANTHEM BCBS | OTHER | 64008899 | 05 | KY |   | MEDICAID | 6710131 | 05 | VA |   | MEDICAID | 0110075-000 | 05 | WV |   | MEDICAID |