Healthcare Provider Details

I. General information

NPI: 1366464950
Provider Name (Legal Business Name): KRISTINE JANE THAYER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MEDICAL CENTER DR STE 2500
HUNTINGTON WV
25701-3657
US

IV. Provider business mailing address

12232 N LEDGES DR
ROSCOE IL
61073-9612
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1200
  • Fax:
Mailing address:
  • Phone: 815-262-7241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number49252
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number77958
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberME 72169
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number25MA05751800
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number036127325
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number35-097350
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number016753
License Number StateME
# 8
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number246981
License Number StateNY
# 9
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number28316
License Number StateOK
# 10
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number31075
License Number StateWV
# 11
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number036127325
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: