Provider Demographics
NPI:1518069012
Name:THOMPSON, EDWARD EUGENE (MSCCCA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:EUGENE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MSCCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2708
Mailing Address - Country:US
Mailing Address - Phone:601-249-3254
Mailing Address - Fax:601-249-3957
Practice Address - Street 1:310 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2708
Practice Address - Country:US
Practice Address - Phone:601-249-3254
Practice Address - Fax:601-249-3957
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA0025231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00075016Medicaid
MS00075016Medicaid