MEDICARE: DR. THOMAS MICHAEL ADAMCZAK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901003746	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	203050498	OTHER	MI	TAX ID
2	383628290	OTHER	MI	TAX ID
3	900F210170	OTHER	MI	BCBS OF MICHIGAN
4	900F111560	OTHER	MI	BCBS OF MICHIGAN

General Provider Information

NPI Number	:	1083614911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS MICHAEL ADAMCZAK O.D.

Provider Business Mailing Address
First Line	:	105 W EXCHANGE ST
Second Line	:
City	:	SPRING LAKE
State	:	MI
Zip	:	49456-2024
Country	:	US
Telephone Number	:	616-846-0620
Fax Number	:	616-844-6079

Provider Business Practice Location Address
First Line	:	1315 E COLBY ST
Second Line	:	SUITE A
City	:	WHITEHALL
State	:	MI
Zip	:	49461-1283
Country	:	US
Telephone Number	:	231-894-9300
Fax Number	:	231-894-9301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	02/17/2015

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