Healthcare Provider Details

I. General information

NPI: 1952627853
Provider Name (Legal Business Name): EARL VAN HORN THOMPSON IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2010
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2123 AUBURN AVE
CINCINNATI OH
45219-2906
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-929-0104
  • Fax: 513-929-4369
Mailing address:
  • Phone: 513-585-5506
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD456123
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number35.129254
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: