Provider Demographics
NPI:1982823639
Name:WITHAM, THOMAS MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:WITHAM
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:PO BOX Q
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-4917
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-942-9610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084261207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00434448OtherRAILROAD MEDICARE
MI5218377Medicaid
MITW084261OtherBLUE CROSS BLUE SHIELD
MI5218377Medicaid