Basic Information
Provider Information | |||||||||
NPI: | 1790760734 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THAME | ||||||||
FirstName: | CRAIG | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1547 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462061547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8774400482 | ||||||||
FaxNumber: | 3177055060 | ||||||||
Practice Location | |||||||||
Address1: | 5352 LINTON BLVD | ||||||||
Address2: | ATTN: RADIOLOGY DEPT | ||||||||
City: | DELRAY BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334846514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5614984440 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2005 | ||||||||
LastUpdateDate: | 04/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 25MA06149100 | NJ | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 101490 | FL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 149MP | 01 | FL | BCBS | OTHER | 002555400 | 05 | FL |   | MEDICAID |