Healthcare Provider Details

I. General information

NPI: 1295750107
Provider Name (Legal Business Name): KISHORE THAMPY, M.D.,S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 US 1 S
ST AUGUSTINE FL
32086-3708
US

IV. Provider business mailing address

PO BOX 388320
CHICAGO IL
60638-8320
US

V. Phone/Fax

Practice location:
  • Phone: 563-599-9396
  • Fax:
Mailing address:
  • Phone: 773-767-4600
  • Fax: 776-767-8320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KISHORE THAMPY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 563-584-2324