Healthcare Provider Details

I. General information

NPI: 1154144301
Provider Name (Legal Business Name): JEROME CLARENCE THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1834 GEORGE AVE
ANNAPOLIS MD
21401-4103
US

IV. Provider business mailing address

1030 SPA RD APT C
ANNAPOLIS MD
21403-1168
US

V. Phone/Fax

Practice location:
  • Phone: 443-441-0631
  • Fax:
Mailing address:
  • Phone: 410-330-5992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: