Provider Demographics
NPI:1659358240
Name:THOMPSON, LARRY G (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:G
Last Name:THOMPSON
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 1:416 E MONROE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2360
Mailing Address - Country:US
Mailing Address - Phone:574-232-8119
Mailing Address - Fax:574-288-0235
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:MEMORIAL HOSPITAL
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-232-8119
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021585207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE19585Medicare UPIN
IN236080OMedicare ID - Type Unspecified