Provider Demographics
NPI:1619978327
Name:THOMAS, ROBERT LEE IV (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:THOMAS
Suffix:IV
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:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-0340
Mailing Address - Country:US
Mailing Address - Phone:606-278-7509
Mailing Address - Fax:
Practice Address - Street 1:123 N 19TH ST
Practice Address - Street 2:SUITE B301
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2865
Practice Address - Country:US
Practice Address - Phone:606-248-7509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12835208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3028439Medicaid
KY64254337Medicaid
TN020031760Medicare PIN
TN3028439Medicare PIN
KY020025859Medicare PIN
KY0207501Medicare PIN
TN3028439Medicaid