Healthcare Provider Details

I. General information

NPI: 1881904605
Provider Name (Legal Business Name): THOMAS PARK M.D. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23077 GREENFIELD RD SUITE 257
SOUTHFIELD MI
48075-3709
US

IV. Provider business mailing address

23077 GREENFIELD RD SUITE 257
SOUTHFIELD MI
48075-3709
US

V. Phone/Fax

Practice location:
  • Phone: 248-552-0044
  • Fax: 248-423-7777
Mailing address:
  • Phone: 248-552-0044
  • Fax: 248-423-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number4301040933
License Number StateMI

VIII. Authorized Official

Name: DR. THOMAS T PARK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 248-552-0044