Provider Demographics
NPI:1275648123
Name:PROSE, THOMAS MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MARK
Last Name:PROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:21333 HAGGERTY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5510
Mailing Address - Country:US
Mailing Address - Phone:248-662-0250
Mailing Address - Fax:248-662-9844
Practice Address - Street 1:21333 HAGGERTY RD
Practice Address - Street 2:SUITE 150
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-5510
Practice Address - Country:US
Practice Address - Phone:248-662-0250
Practice Address - Fax:248-662-9844
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 91109207R00000X
GA052622207R00000X
IDM-9253207R00000X
MI4301046178207R00000X
MO2003003395207R00000X
OH35-07-2106-P207R00000X
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1960245Medicaid
OH2008473Medicaid
A79804Medicare UPIN
OHPR0821822Medicare ID - Type Unspecified
OH2008473Medicaid
MI1960245Medicaid