Healthcare Provider Details

I. General information

NPI: 1376649095
Provider Name (Legal Business Name): KENNETH M THOMPSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MICHIGAN AVE STE 245A
LANSING MI
48912-1800
US

IV. Provider business mailing address

PO BOX 13008
LANSING MI
48901-3008
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-5710
  • Fax: 517-364-5717
Mailing address:
  • Phone: 517-364-6253
  • Fax: 517-364-6208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301046262
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: