Provider Demographics
NPI:1508201393
Name:JU, TOM (MD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:JU
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 1:960 HOLCOMB BRIDGE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1963
Mailing Address - Country:US
Mailing Address - Phone:770-988-7246
Mailing Address - Fax:770-988-7247
Practice Address - Street 1:960 HOLCOMB BRIDGE RD STE 150
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1963
Practice Address - Country:US
Practice Address - Phone:770-988-7246
Practice Address - Fax:770-988-7247
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201801276207LP2900X
GA89892208VP0014X
MI4301103471207LP2900X
SCMD52148207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNN3604AOtherMEDICARE NORTH CAROLINA
SCSCD3676655OtherMEDICARE SOUTH CAROLINA
SC521484Medicaid
SCSCD367560OtherMEDICARE SOUTH CAROLINA