Provider Demographics
NPI:1093768574
Name:MACHOLAN, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MACHOLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:3380 44TH ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2461
Practice Address - Country:US
Practice Address - Phone:616-685-8250
Practice Address - Fax:616-532-9564
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2900180Medicaid
MI3415715Medicaid
MI4187712Medicaid
MI4187730Medicaid
MI4160942Medicaid
MI4876824Medicaid
MI4160942Medicaid
MIM02830033Medicare ID - Type Unspecified
MIP32930148Medicare ID - Type Unspecified
MI4876824Medicaid
MI3415715Medicaid