Healthcare Provider Details

I. General information

NPI: 1407800410
Provider Name (Legal Business Name): JOHN G. THORNBURG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W FARIS RD
GREENVILLE SC
29605-4444
US

IV. Provider business mailing address

ONE INDEPENDENCE POINTE SUITE 212
GREENVILLE SC
29615-4566
US

V. Phone/Fax

Practice location:
  • Phone: 864-295-4410
  • Fax: 864-295-5694
Mailing address:
  • Phone: 864-797-6044
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number6009
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: