Provider Demographics
NPI:1780627018
Name:GIANCARLO, THOMAS (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GIANCARLO
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 1:34025 HARPER
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48043
Mailing Address - Country:US
Mailing Address - Phone:586-445-9900
Mailing Address - Fax:586-445-2641
Practice Address - Street 1:34025 HARPER
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48043
Practice Address - Country:US
Practice Address - Phone:586-445-9900
Practice Address - Fax:586-445-2641
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010085812084N0400X, 2084N0600X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1780627018OtherTGDOPC MD ID
MIP32190001OtherTGDOPC MR ID
MI3195326Medicaid
MI319532611Medicaid
MI700E010320OtherMNA BC ID
MI700E020410OtherTGDOPC BC PIN
MIP32190001OtherTGDOPC MR ID
MI0M16540001Medicare PIN