Healthcare Provider Details

I. General information

NPI: 1619978327
Provider Name (Legal Business Name): ROBERT LEE THOMAS IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 N 19TH ST SUITE B301
MIDDLESBORO KY
40965-2865
US

IV. Provider business mailing address

PO BOX 340
MIDDLESBORO KY
40965-0340
US

V. Phone/Fax

Practice location:
  • Phone: 606-248-7509
  • Fax:
Mailing address:
  • Phone: 606-278-7509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number12835
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: