Provider Demographics
NPI:1457417420
Name:CHWIERUT, THOMAS J (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:CHWIERUT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 W 9 MILE RD STE B
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1779
Mailing Address - Country:US
Mailing Address - Phone:248-544-1333
Mailing Address - Fax:248-545-8395
Practice Address - Street 1:641 W 9 MILE RD STE B
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1779
Practice Address - Country:US
Practice Address - Phone:248-544-1333
Practice Address - Fax:248-545-8395
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITC006241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0156328805OtherBCBSM
MI4346390Medicaid
MI0156328805OtherBCBSM
MI5632880Medicare ID - Type Unspecified