Provider Demographics
NPI:1245231984
Name:WHITESELL, THOMAS
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:WHITESELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 DAN PROCTOR DR.
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:ST MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558
Mailing Address - Country:US
Mailing Address - Phone:912-882-6767
Mailing Address - Fax:912-882-6411
Practice Address - Street 1:2060 DAN PROCTOR DR.
Practice Address - Street 2:SUITE 2100
Practice Address - City:ST MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558
Practice Address - Country:US
Practice Address - Phone:912-882-6767
Practice Address - Fax:912-882-6411
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11BDWRNMedicare ID - Type Unspecified
H82764Medicare UPIN