Provider Demographics
NPI:1053321075
Name:KIDD, THOMAS ALI JR (PAC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALI
Last Name:KIDD
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1671
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-1671
Mailing Address - Country:US
Mailing Address - Phone:240-964-8342
Mailing Address - Fax:240-964-8337
Practice Address - Street 1:190 CAMPUS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601
Practice Address - Country:US
Practice Address - Phone:540-662-0306
Practice Address - Fax:540-662-5845
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000621363A00000X
WV1053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970016137OtherRAILROAD MEDICARE