Provider Demographics
NPI:1851474977
Name:ARCHAMBEAU, THOMAS JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:ARCHAMBEAU
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 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7339
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9746
Practice Address - Country:US
Practice Address - Phone:616-363-7339
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010455662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1691138Medicaid
MI2726185Medicaid
MI200000001150OtherPHP OF MIDMICHIGAN
MI1691094Medicaid
MI300023165OtherRAILROAD MEDICARE
MI300023183OtherRAILROAD MEDICARE
MI200000001150OtherPHP OF MIDMICHIGAN
MI300023165OtherRAILROAD MEDICARE
MI0C37603005Medicare ID - Type Unspecified