Basic Information
| Provider Information | |||||||||
| NPI: | 1649204116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 SISKIYOU BLVD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975202125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414820342 | ||||||||
| FaxNumber: | 5414826986 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 SISKIYOU BLVD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975202125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414820342 | ||||||||
| FaxNumber: | 5414826986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| 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 | 204D00000X | DO20413 | OR | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
ID Information
| ID | Type | State | Issuer | Description | 150137 | 05 | OR | MEDICAID |