Healthcare Provider Details

I. General information

NPI: 1861458374
Provider Name (Legal Business Name): DIANE SUE THOMAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W HIGH ST
LEBANON KY
40033
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 270-692-5811
  • Fax: 270-692-3863
Mailing address:
  • Phone: 270-858-6655
  • Fax: 270-858-4607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32504
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number32504
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: