Healthcare Provider Details

I. General information

NPI: 1184817363
Provider Name (Legal Business Name): KEVIN ROBERT THOMAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MARBLE MILL ROAD
MARIETTA GA
30060-1130
US

IV. Provider business mailing address

111 MARBLE MILL ROAD
MARIETTA GA
30060-1130
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1013
  • Fax: 770-514-5996
Mailing address:
  • Phone: 770-422-1013
  • Fax: 770-514-5996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number0063033
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: