Provider Demographics
NPI:1861489064
Name:THOMPSON, JOEL R (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:R
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 1:945 82ND PKWY
Mailing Address - Street 2:STE 3
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4610
Mailing Address - Country:US
Mailing Address - Phone:843-449-3381
Mailing Address - Fax:843-839-0275
Practice Address - Street 1:945 82ND PKWY
Practice Address - Street 2:STE 3
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4610
Practice Address - Country:US
Practice Address - Phone:843-449-3381
Practice Address - Fax:843-839-0275
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9102207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC091028Medicaid
SC091028Medicaid
D17659Medicare UPIN