Basic Information
| Provider Information | |||||||||
| NPI: | 1659359396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3200 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043884170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 11/13/2008 | ||||||||
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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 | 207P00000X | 17538 | WV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1053229 | 01 | WV | WV DWC | OTHER | 17538 | 01 | WV | LICENSE | OTHER | 1801525000 | 05 | WV | MEDICAID | 001718055 | 01 | WV | WV BCBS | OTHER |