Provider Demographics
NPI:1639293038
Name:WALWORTH, TOM MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:MICHAEL
Last Name:WALWORTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E CHICAGO RD
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-1971
Mailing Address - Country:US
Mailing Address - Phone:269-651-7814
Mailing Address - Fax:
Practice Address - Street 1:1101 E CHICAGO RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1971
Practice Address - Country:US
Practice Address - Phone:269-651-7814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301003023111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOG55019Medicare UPIN