Provider Demographics
NPI:1164406146
Name:RATHKAMP, WALTER THAD (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:THAD
Last Name:RATHKAMP
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 1:7340 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-8402
Mailing Address - Country:US
Mailing Address - Phone:989-695-8014
Mailing Address - Fax:989-695-5810
Practice Address - Street 1:7340 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:MI
Practice Address - Zip Code:48623
Practice Address - Country:US
Practice Address - Phone:989-695-8014
Practice Address - Fax:989-695-5810
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00110021OtherRR MEDICARE
MI4527494Medicaid
MIG86121Medicare UPIN
MI0N86121Medicare UPIN