Basic Information
| Provider Information | |||||||||
| NPI: | 1003018748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 SAINT VINCENT CIR STE 502 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015580200 | ||||||||
| FaxNumber: | 5015580201 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 SAINT VINCENT CIR STE 502 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015580200 | ||||||||
| FaxNumber: | 5015580201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 04/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | E5212 | AR | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 07080011000 | 01 | QUALCHOICE | OTHER | 165495001 | 05 | AR | MEDICAID |