Healthcare Provider Details

I. General information

NPI: 1902907819
Provider Name (Legal Business Name): THOMAS W WAKEFIELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 EAST MEDICAL CENTER DR 3RD FLOOR CARDIOVASCULAR CENTER RECP B
ANN ARBOR MI
48109-5329
US

IV. Provider business mailing address

3621 S STATE ST 700 KMS PLACE
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-5850
  • Fax:
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301042329
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number4301042329
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301042329
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: