Provider Demographics
NPI:1417950346
Name:THOMAS, MADAELIL GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:MADAELIL
Middle Name:GEORGE
Last Name:THOMAS
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 1:1150 ROBERT BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2004
Mailing Address - Country:US
Mailing Address - Phone:985-649-2883
Mailing Address - Fax:985-649-2953
Practice Address - Street 1:1150 ROBERT BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2004
Practice Address - Country:US
Practice Address - Phone:985-649-2883
Practice Address - Fax:985-649-2953
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2009-04-13
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
LA05592R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1316067Medicaid
LA1316067Medicaid
LAD79737Medicare UPIN