Provider Demographics
NPI:1821172362
Name:THOMPSON, SAM (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
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 1:425 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-1762
Mailing Address - Country:US
Mailing Address - Phone:607-732-1310
Mailing Address - Fax:607-733-0940
Practice Address - Street 1:722 W WATER ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-2435
Practice Address - Country:US
Practice Address - Phone:607-271-2050
Practice Address - Fax:607-271-2099
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195774207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2504011OtherGHI
NYQ70080Medicare ID - Type Unspecified
F00358Medicare UPIN