Provider Demographics
NPI:1679643811
Name:RHODIN, THOR ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:THOR
Middle Name:ROBERT
Last Name:RHODIN
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 1:2500 NESCONSET HWY
Mailing Address - Street 2:BLDG 10D
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-981-2663
Mailing Address - Fax:
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:BLDG 10D
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-981-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17149207X00000X
NY288261207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC171495Medicaid
SCA547580281Medicare PIN