Provider Demographics
NPI:1730116849
Name:THOMPSON, BRENT C (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:C
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:PO BOX 2802
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48123-2929
Mailing Address - Country:US
Mailing Address - Phone:313-359-7650
Mailing Address - Fax:313-359-7660
Practice Address - Street 1:840 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2319
Practice Address - Country:US
Practice Address - Phone:313-359-7650
Practice Address - Fax:313-359-7660
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010541752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3082556Medicaid
MIH26272041Medicare PIN
MI3082556Medicaid
MIH26274041Medicare PIN