Provider Demographics
NPI:1508808023
Name:THOMPSON, MICHELLE (MPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:GERDOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:2540 PULASKI HWY STE B
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-2610
Practice Address - Country:US
Practice Address - Phone:410-339-1960
Practice Address - Fax:443-941-9441
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ100001445225100000X
PAPT013241L225100000X
MD21462225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2003131000OtherAMERIHEALTH
1327049OtherPABS
MD5070-0033OtherCAREFIRST
MD61809611OtherCAREFIRST
11416966OtherCAQH
1327049OtherPABS
PA2003131000OtherAMERIHEALTH
$$$$$$$$$OtherCHAMPUS
P00132537Medicare PIN
MD306PS041Medicare PIN
MD5070-0033OtherCAREFIRST