Provider Demographics
NPI:1629299268
Name:THOMPSON, GLEN III (CSA)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:THOMPSON
Suffix:III
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 RAVEN DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403
Mailing Address - Country:US
Mailing Address - Phone:859-200-3356
Mailing Address - Fax:502-451-9291
Practice Address - Street 1:138 RAVEN DR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403
Practice Address - Country:US
Practice Address - Phone:859-200-3356
Practice Address - Fax:502-451-9291
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2222246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000493588OtherANTHEM