Provider Demographics
NPI:1457392078
Name:THOMSON, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:THOMSON
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 100
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48068-0100
Mailing Address - Country:US
Mailing Address - Phone:248-849-3485
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043971207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103435389Medicaid
MI104356412Medicaid
MIMT043971OtherBC/BS OF MICHIGAN
MI104341447Medicaid
MIE26428Medicare UPIN
MI104341447Medicaid