Healthcare Provider Details

I. General information

NPI: 1699963322
Provider Name (Legal Business Name): THOMAS C. THORNBERRY, M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 EVANS AVE
MT STERLING KY
40353-9700
US

IV. Provider business mailing address

260 EVANS AVE
MT STERLING KY
40353-9700
US

V. Phone/Fax

Practice location:
  • Phone: 859-498-7345
  • Fax: 859-498-3780
Mailing address:
  • Phone: 859-498-7345
  • Fax: 859-498-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29071
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number29071
License Number StateKY

VIII. Authorized Official

Name: THOMAS C THORNBERRY
Title or Position: OWNER
Credential: MD
Phone: 859-498-7345