1083667174 NPI number — THOMAS WERTZ DO

Table of content: THOMAS WERTZ DO (NPI 1083667174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083667174 NPI number — THOMAS WERTZ DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WERTZ
Provider First Name:
THOMAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083667174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 GREEN RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-1598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 E MICHIGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAYLING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49738-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-348-5461
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X , with the licence number:  009724 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3409173 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3409128 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: TW009724 . This is a "BLUE CROSS/ BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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