Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0102X | Surgical Critical Care | 01042586A | IN |
NPI | 1356346027 |
---|---|
Provider Name | Roland Lincoln Thomas |
First Address | Chesterton, IN 46304-8708 |
Second Address | Valparaiso, IN 46383 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2005 |
Last Update Date | 15/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000082453 | ANTHEM (01) | IN |
100424620 | (05) | IN |
F01326 | (02) |