Healthcare Provider Details

I. General information

NPI: 1508821901
Provider Name (Legal Business Name): THOMAS W PFENNIG D.O., FAOCO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 44TH ST SW
WYOMING MI
49509-4395
US

IV. Provider business mailing address

1555 44TH ST SW
WYOMING MI
49509-4395
US

V. Phone/Fax

Practice location:
  • Phone: 616-249-8000
  • Fax: 616-249-8088
Mailing address:
  • Phone: 616-249-8000
  • Fax: 616-249-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5101009647
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: