Provider Demographics
NPI:1386705705
Name:THOMPSON, PHIL (DO)
Entity type:Individual
Prefix:DR
First Name:PHIL
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DO
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 10
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:MS
Mailing Address - Zip Code:39153-0010
Mailing Address - Country:US
Mailing Address - Phone:601-782-9801
Mailing Address - Fax:601-782-9955
Practice Address - Street 1:342 MAGNOLIA DRIVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153
Practice Address - Country:US
Practice Address - Phone:601-782-9801
Practice Address - Fax:601-782-9955
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640699015OtherBLUE CROSS BLUE SHIELD
MS640699015OtherACORDIA NATIONAL
MS00014663Medicaid
MS00014663Medicaid