Provider Demographics
NPI:1346414620
Name:THOMAS A MALEC MD PC
Entity Type:Organization
Organization Name:THOMAS A MALEC MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MALEC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-459-3564
Mailing Address - Street 1:515 LAKESIDE DR SE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2931
Mailing Address - Country:US
Mailing Address - Phone:616-459-3564
Mailing Address - Fax:616-459-3868
Practice Address - Street 1:515 LAKESIDE DR SE
Practice Address - Street 2:SUITE 207
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2931
Practice Address - Country:US
Practice Address - Phone:616-459-3564
Practice Address - Fax:616-459-3868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301026401302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101059530Medicaid
MI101059530Medicaid
MI0415692Medicare PIN