Provider Demographics
NPI:1477762441
Name:THORESON, REBECCA L (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:THORESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-657-4407
Mailing Address - Fax:269-657-0965
Practice Address - Street 1:404 HAZEN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1040
Practice Address - Country:US
Practice Address - Phone:269-657-4407
Practice Address - Fax:269-657-0965
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2014-10-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IAR7645208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1477762441Medicaid
MI1235131137OtherBCBSM - BLH TAX ID
MI1235131137OtherBCBS M - BLH
MIH06612077 - BLHMedicare PIN