Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 032919 | MI |
NPI | 1043419591 |
---|---|
Provider Name | Dr. Thomas K Mathew |
First Address | Adrian, MI 49221-1367 |
Second Address | Adrian, MI 49221-1367 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2007 |
Last Update Date | 15/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1368616 | (05) | MI |
3407869482 | BLUE CROSS AND BLUE SHIEL (01) | MI |