Provider Demographics
NPI:1992793251
Name:THOMPSON, KENNETH ALLAN (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLAN
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 634706
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-4706
Mailing Address - Country:US
Mailing Address - Phone:662-772-3260
Mailing Address - Fax:
Practice Address - Street 1:7601 SOUTHCREST PKWY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4739
Practice Address - Country:US
Practice Address - Phone:662-772-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00025767207P00000X
MS19372207P00000X
TN41139207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3829824Medicaid
TN4133803OtherBLUE CROSS
MS07781813Medicaid
TNP00388668OtherRAILROAD MEDICARE
TN3829824Medicare PIN
TN4133803OtherBLUE CROSS
ALI12917Medicare UPIN
MS930003719Medicare PIN