Basic Information
| Provider Information | |||||||||
| NPI: | 1811919251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONNON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 EXPLORER ST | ||||||||
| Address2: | |||||||||
| City: | GWINN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498412813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063464924 | ||||||||
| FaxNumber: | 9063466474 | ||||||||
| Practice Location | |||||||||
| Address1: | 945 9TH ST | ||||||||
| Address2: | |||||||||
| City: | LAKE LINDEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499451100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064831030 | ||||||||
| FaxNumber: | 9062960521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301044670 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4795520 | 05 | MI | MEDICAID | TM044670 | 01 | MI | MI BCBS PIN | OTHER | 34801400 | 05 | WI | MEDICAID |