Provider Demographics
NPI:1770798142
Name:TOMS P. MATHEW M.D., P.C.
Entity type:Organization
Organization Name:TOMS P. MATHEW M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOMS
Authorized Official - Middle Name:P
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-753-4320
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-0725
Mailing Address - Country:US
Mailing Address - Phone:734-753-4350
Mailing Address - Fax:
Practice Address - Street 1:19270 HANNAN RD
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:MI
Practice Address - Zip Code:48164-9811
Practice Address - Country:US
Practice Address - Phone:734-753-4350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058860207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4095933Medicaid
MI4095933Medicaid
MIF81499Medicare UPIN