Provider Demographics
NPI:1548445331
Name:THOMAS DEKORTE
Entity type:Organization
Organization Name:THOMAS DEKORTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:DEKORTE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:231-547-4662
Mailing Address - Street 1:1773 WOODSIDE TRL NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2580
Mailing Address - Country:US
Mailing Address - Phone:616-453-1835
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:1404 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-2603
Practice Address - Country:US
Practice Address - Phone:231-547-4662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITD001078213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4851550000OtherBCBSM
MI1441583Medicaid
MI0801100001Medicare NSC
MI4851550000OtherBCBSM
MI5155000Medicare PIN