Provider Demographics
NPI:1790154011
Name:THOMSON, ELIJAH
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:THOMSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9708 LANGLEY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-3882
Mailing Address - Country:US
Mailing Address - Phone:410-499-3201
Mailing Address - Fax:
Practice Address - Street 1:9708 LANGLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-3882
Practice Address - Country:US
Practice Address - Phone:443-681-6352
Practice Address - Fax:443-681-6352
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPSC5373OtherTRANSPORTATION PROVIDER