Healthcare Provider Details

I. General information

NPI: 1548445331
Provider Name (Legal Business Name): THOMAS DEKORTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 BRIDGE ST
CHARLEVOIX MI
49720-2603
US

IV. Provider business mailing address

1773 WOODSIDE TRL NW
GRAND RAPIDS MI
49504-2580
US

V. Phone/Fax

Practice location:
  • Phone: 231-547-4662
  • Fax:
Mailing address:
  • Phone: 616-453-1835
  • Fax: 616-453-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberTD001078
License Number StateMI

VIII. Authorized Official

Name: THOMAS B DEKORTE
Title or Position: PRESIDENT
Credential: DPM
Phone: 231-547-4662