Provider Demographics
NPI:1659556264
Name:G.R. THOMAS JR OD PA
Entity Type:Organization
Organization Name:G.R. THOMAS JR OD PA
Other - Org Name:MAPLE GROVE EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:763-420-6981
Mailing Address - Street 1:7880 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7081
Mailing Address - Country:US
Mailing Address - Phone:763-420-6981
Mailing Address - Fax:763-773-7253
Practice Address - Street 1:7880 MAINSTREET
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7081
Practice Address - Country:US
Practice Address - Phone:763-420-6981
Practice Address - Fax:763-773-7253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1457152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN652323400Medicaid
MNT39345Medicare UPIN
0249030001Medicare NSC
MNC01951Medicare PIN