Provider Demographics
NPI:1295819332
Name:THOMAS J HAVERBUSH MD PC
Entity type:Organization
Organization Name:THOMAS J HAVERBUSH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-463-6092
Mailing Address - Street 1:315 E WARWICK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1083
Mailing Address - Country:US
Mailing Address - Phone:989-463-6092
Mailing Address - Fax:989-463-8914
Practice Address - Street 1:315 E WARWICK DR
Practice Address - Street 2:SUITE A
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1083
Practice Address - Country:US
Practice Address - Phone:989-463-6092
Practice Address - Fax:989-463-8914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027074207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101394750Medicaid
MI101394750Medicaid
MI0P03010Medicare PIN
MI0591060001Medicare NSC
MIP03010001Medicare ID - Type Unspecified