Provider Demographics
NPI:1366489635
Name:SRUTWA, THADDEUS P (MD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:P
Last Name:SRUTWA
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 1:16986 ROBBINS RD STE 180
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2795
Mailing Address - Country:US
Mailing Address - Phone:616-229-3295
Mailing Address - Fax:616-229-3295
Practice Address - Street 1:16986 ROBBINS RD STE 180
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2795
Practice Address - Country:US
Practice Address - Phone:616-213-0253
Practice Address - Fax:616-296-2423
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045363204D00000X
MI4301045353208VP0000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0700125OtherBLUE CROSS BLUE SHEILD
MIN90970001Medicare PIN