Basic Information
| Provider Information | |||||||||
| NPI: | 1962637926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THEKKEKANDAM | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., ABFM, CAQSM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368327000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1635 NC HIGHWAY 66 S | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272843854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369921770 | ||||||||
| FaxNumber: | 3369921776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2009 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 2012-01709 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.