Provider Demographics
NPI:1083782858
Name:DR THOMAS J MICKELSEN, P.C.
Entity Type:Organization
Organization Name:DR THOMAS J MICKELSEN, P.C.
Other - Org Name:MICKELSEN CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MICKELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-462-2262
Mailing Address - Street 1:6635 WING LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-2955
Mailing Address - Country:US
Mailing Address - Phone:248-626-1116
Mailing Address - Fax:
Practice Address - Street 1:37625 ANN ARBOR RD
Practice Address - Street 2:SUITE 111
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2400
Practice Address - Country:US
Practice Address - Phone:734-462-2262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007193111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3231745Medicaid
MIU60541OtherHAP PROVIDER NUMBER
MICH820105OtherMCARE PROVIDER NUMBER
MI5599151OtherAETNA PROVIDER NUMBER
MI3231745Medicaid
MIU60541Medicare UPIN