Provider Demographics
NPI:1760442636
Name:GRAVELYN, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:GRAVELYN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR
Mailing Address - Street 2:PO BOX 0446 LOBBY J
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:SUITE 3111
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1014
Practice Address - Country:US
Practice Address - Phone:734-712-7688
Practice Address - Fax:734-712-7056
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-10-28
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Provider Licenses
StateLicense IDTaxonomies
MITG044869207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI423968610Medicaid
MIA77489Medicare UPIN
MI0M88740002Medicare ID - Type Unspecified