Provider Demographics
NPI:1215956156
Name:THOMPSON, ERVIN M (MD)
Entity type:Individual
Prefix:
First Name:ERVIN
Middle Name:M
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 BILLINGSLEY RD
Practice Address - Street 2:STE 102
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5055
Practice Address - Country:US
Practice Address - Phone:704-444-2574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC212372084P0800X
SC294102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN21237Medicaid
NC82920OtherBCBS
NC1215956156Medicaid
NC7982920Medicaid
NC201911JMedicare PIN
NC7982920Medicaid
NC82920OtherBCBS