Provider Demographics
NPI:1639266679
Name:MICK, THOMAS MARCUS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MARCUS
Last Name:MICK
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 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0002
Mailing Address - Country:US
Mailing Address - Phone:216-444-5807
Mailing Address - Fax:216-587-8646
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0002
Practice Address - Country:US
Practice Address - Phone:216-444-5807
Practice Address - Fax:216-587-8646
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60 238722207RS0010X, 207R00000X, 2084P0800X
OH35.137477207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2D157NW221Medicare PIN
NYWNW221Medicare PIN