Provider Demographics
NPI:1083667174
Name:WERTZ, THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WERTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 GREEN RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-1312
Practice Address - Country:US
Practice Address - Phone:989-348-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI009724207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3409173Medicaid
MI3409128Medicaid
MITW009724OtherBLUE CROSS/ BLUE SHIELD
MIM60660018Medicare PIN
MITW009724OtherBLUE CROSS/ BLUE SHIELD