Basic Information
| Provider Information | |||||||||
| NPI: | 1538797113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VAN THOMAS | ||||||||
| OtherFirstName: | ANDY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 311 ALBERT SABIN WAY | ||||||||
| Address2: | 0559 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452292838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135585825 | ||||||||
| FaxNumber: | 5135588838 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 ALBERT SABIN WAY | ||||||||
| Address2: | 0559 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452292838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135585825 | ||||||||
| FaxNumber: | 5135588838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2020 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OH | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.