=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346414620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS A MALEC MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2008
-----------------------------------------------------
Last Update Date | 08/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 LAKESIDE DR SE SUITE 207
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-459-3564
-----------------------------------------------------
Fax | 616-459-3868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 LAKESIDE DR SE SUITE 207
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-459-3564
-----------------------------------------------------
Fax | 616-459-3868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OF CORPORATION
-----------------------------------------------------
Name | DR. THOMAS ANTHONY MALEC
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 616-459-3564
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 4301026401
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------