Provider Demographics
NPI:1508167206
Name:THOMAS G. WAYNE M.D., P.L.L.C.
Entity Type:Organization
Organization Name:THOMAS G. WAYNE M.D., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:WAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-326-0858
Mailing Address - Street 1:4150 S. RIVER RD.
Mailing Address - Street 2:SUITE1
Mailing Address - City:EAST CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-2915
Mailing Address - Country:US
Mailing Address - Phone:810-326-0858
Mailing Address - Fax:810-326-0933
Practice Address - Street 1:4150 S RIVER RD
Practice Address - Street 2:SUITE1
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2915
Practice Address - Country:US
Practice Address - Phone:810-326-0858
Practice Address - Fax:810-326-0933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON22610OtherMEDICARE ID-TYPE UNSPECIFIED
0807408272OtherBCBSM
MI4277711Medicaid
0807408272OtherBCBSM