Provider Demographics
NPI:1215997077
Name:THOMPSON, KEITH (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
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 1:143 KENNEDY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-3309
Mailing Address - Country:US
Mailing Address - Phone:731-587-5321
Mailing Address - Fax:731-587-2145
Practice Address - Street 1:143 KENNEDY DR
Practice Address - Street 2:SUITE A
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3309
Practice Address - Country:US
Practice Address - Phone:731-587-5321
Practice Address - Fax:731-587-2145
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18049208600000X
TN29386208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36655OtherTLC
TN000000188621OtherUNISON
TN3815542Medicaid
MS07375201Medicaid
TN4128847OtherBCBS
TN4383459OtherAETNA
TN3815542Medicaid
TN4128847OtherBCBS
MS07375201Medicaid