Healthcare Provider Details

I. General information

NPI: 1770215741
Provider Name (Legal Business Name): ERIC GLENN THOMAS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

1149 HUEY RD
DOUGLASVILLE GA
30134-3920
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN258475
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: