1336162122 NPI number — ROBERT L TOMSAK MD, PHD

Table of content: ROBERT L TOMSAK MD, PHD (NPI 1336162122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336162122 NPI number — ROBERT L TOMSAK MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOMSAK
Provider First Name:
ROBERT
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
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:
1336162122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1560 E. MAPLE RD
Provider Second Line Business Mailing Address:
SUITE 400-CREDENTIALING
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48083-1189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-581-5976
Provider Business Mailing Address Fax Number:
248-581-5640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4717 ST ANTOINE
Provider Second Line Business Practice Location Address:
KRESGE EYE INSTITUTE
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-1423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-577-8900
Provider Business Practice Location Address Fax Number:
313-577-0700
Provider Enumeration Date:
07/25/2006

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: 207W00000X , with the licence number:  35-043259 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 4301095698 , 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: 738110 . This is a "BUCKEYE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2386992 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 130023873 . This is a "MCR RR" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00398391 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0445718 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000510698 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000221074 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 364082 . This is a "WELLCARE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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