Basic Information
Provider Information | |||||||||
NPI: | 1811945199 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GENERAL MEDICINE, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 05/05/2006 | ||||||||
LastUpdateDate: | 09/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PROSE | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | MARK | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2486620250 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207RG0300X |   | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | CB2699 | 01 | IL | METRAHEALTH RR | OTHER | 506127307 | 05 | MO |   | MEDICAID | 1452653 | 05 | LA |   | MEDICAID | 09830139 | 01 | IL | BLUE CROSS/BLUE SHIELD | OTHER | 500F329520 | 01 | MI | BLUE CROSS/BLUE SHIELD | OTHER | CC4797 | 01 | MI | METRAHEALTH RR | OTHER | DA1347 | 01 | MI | METRAHEALTH RR | OTHER |