Provider Demographics
NPI:1306005244
Name:ST. THOMAS MEDICAL CLINIC
Entity Type:Organization
Organization Name:ST. THOMAS MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-260-7575
Mailing Address - Street 1:1470 HALFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-3205
Mailing Address - Country:US
Mailing Address - Phone:408-260-7575
Mailing Address - Fax:408-556-6773
Practice Address - Street 1:1470 HALFORD AVE
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-3205
Practice Address - Country:US
Practice Address - Phone:408-260-7575
Practice Address - Fax:408-556-6773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA13417207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA19433Medicare UPIN
CAZZZ21914ZMedicare PIN