Basic Information
| Provider Information | |||||||||
| NPI: | 1447698220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE STE 130 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704280462 | ||||||||
| FaxNumber: | 7704278001 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE STE 130 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704280462 | ||||||||
| FaxNumber: | 7704278001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2013 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | 5101020643 | MI | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | 34.014005 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | 86368 | GA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 86368 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0366962 | 05 | OH | MEDICAID |