Provider Demographics
NPI:1699963322
Name:THOMAS C. THORNBERRY, M.D., LLC
Entity type:Organization
Organization Name:THOMAS C. THORNBERRY, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:THORNBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-498-7345
Mailing Address - Street 1:260 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-9700
Mailing Address - Country:US
Mailing Address - Phone:859-498-7345
Mailing Address - Fax:859-498-3780
Practice Address - Street 1:260 EVANS AVE
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9700
Practice Address - Country:US
Practice Address - Phone:859-498-7345
Practice Address - Fax:859-498-3780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29071207Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9737Medicare PIN