Provider Demographics
NPI:1851404636
Name:THOMAS, PHILOMINA C (MD)
Entity Type:Individual
Prefix:
First Name:PHILOMINA
Middle Name:C
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PHILOMINA
Other - Middle Name:THOMAS
Other - Last Name:CHAKUPURAKAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4727 ST ANTOINE
Mailing Address - Street 2:STE 212
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-833-7266
Mailing Address - Fax:313-833-7085
Practice Address - Street 1:4727 ST ANTOINE
Practice Address - Street 2:STE 212
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-833-7266
Practice Address - Fax:313-833-7085
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040162208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2984591Medicaid
5907164Medicare ID - Type Unspecified
MI2984591Medicaid