Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0102X | Surgical Critical Care | 34.014005 | OH |
N | 2086S0102X | Surgical Critical Care | 5101020643 | MI |
N | 2086S0102X | Surgical Critical Care | 86368 | GA |
Y | 2086S0127X | Trauma Surgeon | 86368 | GA |
NPI | 1447698220 |
---|---|
Provider Name | Dr. Kyle Matthew Thomas |
First Address | Marietta, GA 30060-1156 |
Second Address | Marietta, GA 30060-1156 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2013 |
Last Update Date | 01/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0366962 | (05) | OH |