Basic Information
| Provider Information | |||||||||
| NPI: | 1386638518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THURMOND | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL PARK | ||||||||
| Address2: | SUITE 506 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035401000 | ||||||||
| FaxNumber: | 8035401011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 04/13/2018 | ||||||||
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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 | 207R00000X | 32168 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 037711 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | 32168 | SC | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207UN0901X | 037711 | GA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | 32168 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | AA66502603 | 01 | SC | MEDICARE PTAN | OTHER | P00218467/CM0845 | 01 | GA | RAILROAD MEDICARE | OTHER | 000615337C | 05 | GA | MEDICAID | G37711 | 05 | SC | MEDICAID |