Provider Demographics
NPI:1487181368
Name:THOMAS, KEVIN MATHEW
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MATHEW
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3428
Mailing Address - Country:US
Mailing Address - Phone:765-741-1095
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR # DC046.00
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212
Practice Address - Country:US
Practice Address - Phone:573-882-3101
Practice Address - Fax:573-884-4540
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2018016920208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program