=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326000613
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK T THORNE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2933 MAPLEWOOD AVE 4
-----------------------------------------------------
City | WINSTON-SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-765-0155
-----------------------------------------------------
Fax | 336-765-5494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7036 ORCHARD PATH DR
-----------------------------------------------------
City | CLEMMONS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27012-8222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-766-6289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 34481
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------