=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861458374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE SUE THOMAS M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2006
-----------------------------------------------------
Last Update Date | 12/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 W HIGH ST
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-692-5811
-----------------------------------------------------
Fax | 270-692-3863
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1080
-----------------------------------------------------
City | BURKESVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42717-1080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-858-6655
-----------------------------------------------------
Fax | 270-858-4607
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number | 32504
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 32504
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------