Provider Demographics
NPI:1447204797
Name:THOMAS, GORDON (PT)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 RIVERWALK BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-8190
Mailing Address - Country:US
Mailing Address - Phone:843-379-1966
Mailing Address - Fax:843-379-1967
Practice Address - Street 1:149 RIVERWALK BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-8190
Practice Address - Country:US
Practice Address - Phone:843-379-1966
Practice Address - Fax:843-379-1967
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
010793346OtherTAX ID
SCTH1469Medicaid
P46003Medicare ID - Type Unspecified
SCTH1469Medicaid
SC7812Medicare PIN