Provider Demographics
NPI:1922063452
Name:THORNEWILL, JEREMY L (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
Last Name:THORNEWILL
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4420 DIXIE HWY
Practice Address - Street 2:STE. 114
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2986
Practice Address - Country:US
Practice Address - Phone:502-449-6464
Practice Address - Fax:502-449-6465
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1167891OtherPASSPORT / NMA
IN200414770Medicaid
0000350636OtherANTHEM / NMA
000052155OtherHUMANA / NMA
015654OtherSIHO / NMA
2440217000OtherPASSPORT ADVANTAGE / NMA
3094612001OtherCIGNA / NMA
KY64051808Medicaid
1196970OtherCHA / NMA
KYP00185976OtherRAILROAD MEDICARE
1167891OtherPASSPORT / NMA
3094612001OtherCIGNA / NMA