Provider Demographics
NPI:1871691543
Name:THOMAS, JACK G (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:G
Last Name:THOMAS
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 5501
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5501
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:701-323-5709
Practice Address - Street 1:938 2ND AVE W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3916
Practice Address - Country:US
Practice Address - Phone:701-456-6000
Practice Address - Fax:701-323-5709
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14673Medicaid
ND15743Medicare PIN
NDD26342Medicare UPIN