MEDICARE: MARK EDMUND THOMPSON D.O.

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	2085R0001X	Radiation Oncology Physician	OS10194	FL
2	2085R0203X	Therapeutic Radiology Physician	OS10194	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	310302	OTHER	FL	AVMED
2	02484	OTHER	FL	BLUE CROSS BLUE SHIELD
3	PTAN AG644E	OTHER	FL	LINKED TO GROUP PTAN IE881A EFFECTIVE 08/01/2015
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487646030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK EDMUND THOMPSON D.O.

Provider Business Mailing Address
First Line	:	104 WOODMONT BLVD STE 500
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37205-2245
Country	:	US
Telephone Number	:	559-475-4151
Fax Number	:	559-421-7004

Provider Business Practice Location Address
First Line	:	4520 W US HIGHWAY 90
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-8341
Country	:	US
Telephone Number	:	352-755-0601
Fax Number	:	352-755-0602

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

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	05/05/2025

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