Basic Information
| Provider Information | |||||||||
| NPI: | 1982635462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 636019 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652923000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062726282 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 01/30/2008 | ||||||||
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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 | 052646 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4061474 | 01 | TN | BCBS OF TENNESSEE | OTHER | 027747593B | 05 | GA | MEDICAID | 027747593A | 05 | GA | MEDICAID | P00233185 | 01 | GA | RAILROAD MEDICARE | OTHER |