Provider Demographics
NPI:1407800410
Name:THORNBURG, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:THORNBURG
Suffix:
Gender:M
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:ONE INDEPENDENCE POINTE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4566
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:1210 W FARIS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4444
Practice Address - Country:US
Practice Address - Phone:864-295-4410
Practice Address - Fax:864-295-5694
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC60092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC060098Medicaid
SCB916916814Medicare PIN
SCB916916211Medicare PIN