Basic Information
| Provider Information | |||||||||
| NPI: | 1376535575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWANSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4201 SAINT ANTOINE ST STE 8D | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454275 | ||||||||
| FaxNumber: | 3135774641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 65297 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 11860 | MT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 4301086966 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0938641 | 05 | OH | MEDICAID |