MEDICARE: DR. VINCENT J THOMPSON III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	XT4563777	PA
2	207Q00000X	Family Medicine Physician	MD426812	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	223613YHRN	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1174526180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VINCENT J THOMPSON III M.D.

Provider Business Mailing Address
First Line	:	2020 PENROSE AVENUE
Second Line	:	SUITE A1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145
Country	:	US
Telephone Number	:	267-519-0518
Fax Number	:	267-886-9761

Provider Business Practice Location Address
First Line	:	2020 PENROSE AVENUE
Second Line	:	SUITE A1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145
Country	:	US
Telephone Number	:	267-519-0518
Fax Number	:	267-886-9761

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	10/29/2018

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