Provider Demographics
NPI:1932502176
Name:THOMPSON, ADRIAN SR
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:THOMPSON
Suffix:SR
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 1:23206 GAY STREET
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123
Mailing Address - Country:US
Mailing Address - Phone:216-347-2883
Mailing Address - Fax:216-731-0927
Practice Address - Street 1:23206 GAY STREET
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123
Practice Address - Country:US
Practice Address - Phone:216-347-2883
Practice Address - Fax:216-731-0927
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH80-0579796172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3120732Medicaid