Provider Demographics
NPI:1629050448
Name:MCKENZIE, THOMAS E (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 COUNTY ROAD 545 N
Mailing Address - Street 2:
Mailing Address - City:SKANDIA
Mailing Address - State:MI
Mailing Address - Zip Code:49885-9583
Mailing Address - Country:US
Mailing Address - Phone:906-942-7003
Mailing Address - Fax:
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-225-3406
Practice Address - Fax:906-225-3094
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704207439367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00237828OtherRAILROAD MEDICARE PIN
MI104593293Medicaid
MITM207439OtherBLUESHIELD PIN
MITM207439OtherBLUESHIELD PIN