Provider Demographics
NPI:1366464950
Name:THAYER, KRISTINE JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:JANE
Last Name:THAYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12232 N LEDGES DR
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9612
Mailing Address - Country:US
Mailing Address - Phone:815-262-7241
Mailing Address - Fax:
Practice Address - Street 1:1600 MEDICAL CENTER DR STE 2500
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3657
Practice Address - Country:US
Practice Address - Phone:304-691-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036127325207XP3100X, 2086S0120X
CO492522086S0120X
MT779582086S0120X
FLME 721692086S0120X
NJ25MA057518002086S0120X
OH35-0973502086S0120X
ME0167532086S0120X
NY2469812086S0120X
OK283162086S0120X
WV310752086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEG09507Medicare UPIN