Healthcare Provider Details

I. General information

NPI: 1922485515
Provider Name (Legal Business Name): THOMAS J HENKE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2015
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 KENMOOR AVE SE STE 301
GRAND RAPIDS MI
49546-2395
US

IV. Provider business mailing address

3084 BARONS COVE DR
EDGEWOOD KY
41017-8131
US

V. Phone/Fax

Practice location:
  • Phone: 616-916-8063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number5101025584
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number5101025584
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101025584
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: