Provider Demographics
NPI:1710196951
Name:WILLIAM T. THISTLETHWAITE M.D. PLLC
Entity Type:Organization
Organization Name:WILLIAM T. THISTLETHWAITE M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-629-3331
Mailing Address - Street 1:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42142
Mailing Address - Country:US
Mailing Address - Phone:270-629-3331
Mailing Address - Fax:270-629-3330
Practice Address - Street 1:1012C GLENVIEW DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3424
Practice Address - Country:US
Practice Address - Phone:270-629-3331
Practice Address - Fax:270-629-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000368126OtherANTHEM BLUE CROSS
KY000000368126OtherKENTUCKY ACCESS
KY64048085Medicaid
KY000000368126OtherANTHEM BLUE CROSS
KY000000368126OtherKENTUCKY ACCESS