Provider Demographics
NPI:1679670749
Name:VANWINGEN, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:VANWINGEN
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 1:109 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2095
Mailing Address - Country:US
Mailing Address - Phone:616-842-7406
Mailing Address - Fax:616-844-7056
Practice Address - Street 1:109 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-2095
Practice Address - Country:US
Practice Address - Phone:616-842-7406
Practice Address - Fax:616-844-7056
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042275207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1607001561OtherBCBSM PIN
MI101972282Medicaid
MI382854385OtherTAX ID
MIP52292OtherBCN PIN #
MI0410128Medicare ID - Type Unspecified
MI1607001561OtherBCBSM PIN