Healthcare Provider Details

I. General information

NPI: 1548461114
Provider Name (Legal Business Name): JACOB NATHANIEL THOMAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 PRESTON RIDGE ROAD KAISER PERMANENTE ALPHARETTA MEDICAL OFFICE
ALPHARETTA GA
30201
US

IV. Provider business mailing address

3495 PIEDMONT ROAD, NE NINE PIEDMONT CENTER
ATLANTA GA
30305
US

V. Phone/Fax

Practice location:
  • Phone: 770-663-3181
  • Fax: 904-202-4219
Mailing address:
  • Phone: 404-364-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number65318
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTRN11022
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME106793
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: