Healthcare Provider Details

I. General information

NPI: 1770798142
Provider Name (Legal Business Name): TOMS P. MATHEW M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19270 HANNAN RD
NEW BOSTON MI
48164-9811
US

IV. Provider business mailing address

PO BOX 725
NEW BOSTON MI
48164-0725
US

V. Phone/Fax

Practice location:
  • Phone: 734-753-4350
  • Fax:
Mailing address:
  • Phone: 734-753-4350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301058860
License Number StateMI

VIII. Authorized Official

Name: TOMS P MATHEW
Title or Position: PRESIDENT
Credential: MD
Phone: 734-753-4320