Provider Demographics
NPI:1386638518
Name:THURMOND, CARL W (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:W
Last Name:THURMOND
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:2 MEDICAL PARK
Practice Address - Street 2:SUITE 506
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:803-540-1000
Practice Address - Fax:803-540-1011
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32168207R00000X, 207UN0901X, 207RC0000X
GA037711207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA66502603OtherMEDICARE PTAN
GAP00218467/CM0845OtherRAILROAD MEDICARE
GA000615337CMedicaid
SCG37711Medicaid
GAG69363Medicare UPIN
GA000615337CMedicaid