1215169438 NPI number — DR. THOMAS JAMES MIKULSKI D.O.

Table of content: DR. THOMAS JAMES MIKULSKI D.O. (NPI 1215169438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215169438 NPI number — DR. THOMAS JAMES MIKULSKI D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIKULSKI
Provider First Name:
THOMAS
Provider Middle Name:
JAMES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1215169438
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 BROADWAY AVE NW
Provider Second Line Business Mailing Address:
APT. 620A
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49504-7305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-648-0856
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 JEFFERSON AVE SE
Provider Second Line Business Practice Location Address:
C/O ELOISE MIKA, GREMG
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-4502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-685-6781
Provider Business Practice Location Address Fax Number:
616-685-3064
Provider Enumeration Date:
08/21/2009

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: 207P00000X , with the licence number:  5101018330 , 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)





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