Provider Demographics
NPI:1205266491
Name:THOMAS KNUTH MD PA
Entity type:Organization
Organization Name:THOMAS KNUTH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:VIVIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-552-5333
Mailing Address - Street 1:PO BOX 806403
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-6403
Mailing Address - Country:US
Mailing Address - Phone:586-552-5333
Mailing Address - Fax:586-552-5326
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:PROF BLD 1 SUITE 332
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:586-552-5333
Practice Address - Fax:586-552-5326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-25
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089707174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H28467OtherBCBS MICHIGAN