Provider Demographics
NPI:1245214741
Name:TAVARONE, THOMAS N (MD, FACS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:N
Last Name:TAVARONE
Suffix:
Gender:M
Credentials:MD, FACS
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:421 S BALDWIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2102
Practice Address - Country:US
Practice Address - Phone:616-225-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301082748208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI105452413Medicaid
MIM56400010Medicare PIN