Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 009724 | MI |
NPI | 1083667174 |
---|---|
Provider Name | Thomas Wertz |
First Address | Ann Arbor, MI 48105-1598 |
Second Address | Grayling, MI 49738-1312 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2006 |
Last Update Date | 05/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3409128 | (05) | MI |
3409173 | (05) | MI |
E30266 | (02) | MI |
TW009724 | BLUE CROSS/ BLUE SHIELD (01) | MI |