Provider Demographics
NPI:1881621605
Name:THOMAS, JEFF CC (MD)
Entity type:Individual
Prefix:DR
First Name:JEFF
Middle Name:CC
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2201 W SUDBURY DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3812
Mailing Address - Country:US
Mailing Address - Phone:812-333-1933
Mailing Address - Fax:812-333-3991
Practice Address - Street 1:2201 W SUDBURY DR
Practice Address - Street 2:SUITE C
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3812
Practice Address - Country:US
Practice Address - Phone:812-333-1933
Practice Address - Fax:812-333-3991
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01048577A208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200184760Medicaid
IN200184760Medicaid
IN203010CMedicare ID - Type Unspecified
INM400036980Medicare PIN
IN149290JMedicare ID - Type Unspecified