Provider Demographics
NPI:1508821901
Name:PFENNIG, THOMAS W (DO, FAOCO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:PFENNIG
Suffix:
Gender:M
Credentials:DO, FAOCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 44TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-4395
Mailing Address - Country:US
Mailing Address - Phone:616-249-8000
Mailing Address - Fax:616-249-8088
Practice Address - Street 1:1555 44TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4395
Practice Address - Country:US
Practice Address - Phone:616-249-8000
Practice Address - Fax:616-249-8088
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009647207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2854990Medicaid
MIF28232Medicare UPIN