Basic Information
| Provider Information | |||||||||
| NPI: | 1275648123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROSE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21333 HAGGERTY RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483755510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486620250 | ||||||||
| FaxNumber: | 2486629844 | ||||||||
| Practice Location | |||||||||
| Address1: | 21333 HAGGERTY RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483755510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486620250 | ||||||||
| FaxNumber: | 2486629844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME 91109 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 052622 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | M-9253 | ID | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301046178 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2003003395 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35-07-2106-P | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1960245 | 05 | MI | MEDICAID | 2008473 | 05 | OH | MEDICAID |