Basic Information
Provider Information | |||||||||
NPI: | 1083614911 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ADAMCZAK | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 105 W EXCHANGE ST | ||||||||
Address2: |   | ||||||||
City: | SPRING LAKE | ||||||||
State: | MI | ||||||||
PostalCode: | 494562024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6168460620 | ||||||||
FaxNumber: | 6168446079 | ||||||||
Practice Location | |||||||||
Address1: | 1315 E COLBY ST | ||||||||
Address2: | SUITE A | ||||||||
City: | WHITEHALL | ||||||||
State: | MI | ||||||||
PostalCode: | 494611283 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2318949300 | ||||||||
FaxNumber: | 2318949301 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2005 | ||||||||
LastUpdateDate: | 02/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901003746 | MI | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 203050498 | 01 | MI | TAX ID | OTHER | 383628290 | 01 | MI | TAX ID | OTHER | 900F210170 | 01 | MI | BCBS OF MICHIGAN | OTHER | 900F111560 | 01 | MI | BCBS OF MICHIGAN | OTHER |