Healthcare Provider Details

I. General information

NPI: 1659287308
Provider Name (Legal Business Name): THOMAS JOHN KIDDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LEE ST
BRUNSWICK GA
31520-7132
US

IV. Provider business mailing address

1421 LEE ST
BRUNSWICK GA
31520-7132
US

V. Phone/Fax

Practice location:
  • Phone: 912-265-0007
  • Fax: 912-261-0593
Mailing address:
  • Phone: 912-265-0007
  • Fax: 912-261-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: CATHERINE COLLETT
Title or Position: BILLING COORDINATOR
Credential:
Phone: 912-270-1690