Healthcare Provider Details

I. General information

NPI: 1851404636
Provider Name (Legal Business Name): PHILOMINA C THOMAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PHILOMINA THOMAS CHAKUPURAKAL MD

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 ST ANTOINE STE 212
DETROIT MI
48201
US

IV. Provider business mailing address

4727 ST ANTOINE STE 212
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 313-833-7266
  • Fax: 313-833-7085
Mailing address:
  • Phone: 313-833-7266
  • Fax: 313-833-7085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301040162
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: