Basic Information
| Provider Information | |||||||||
| NPI: | 1861458374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708586655 | ||||||||
| FaxNumber: | 2708584607 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 W HIGH ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706925811 | ||||||||
| FaxNumber: | 2706923863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 32504 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | 32504 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 64325046 | 05 | KY | MEDICAID |