Provider Demographics
NPI:1811945199
Name:GENERAL MEDICINE, P.C.
Entity type:Organization
Organization Name:GENERAL MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:PROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-662-0250
Mailing Address - Street 1:21333 HAGGERTY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5510
Mailing Address - Country:US
Mailing Address - Phone:248-662-0250
Mailing Address - Fax:248-662-9844
Practice Address - Street 1:21333 HAGGERTY RD
Practice Address - Street 2:SUITE 150
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-5510
Practice Address - Country:US
Practice Address - Phone:248-662-0250
Practice Address - Fax:248-662-9844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363L00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCB2699OtherMETRAHEALTH RR
MO506127307Medicaid
LA1452653Medicaid
IL09830139OtherBLUE CROSS/BLUE SHIELD
MI500F329520OtherBLUE CROSS/BLUE SHIELD
MICC4797OtherMETRAHEALTH RR
MIDA1347OtherMETRAHEALTH RR
IL09830139OtherBLUE CROSS/BLUE SHIELD
MO506127307Medicaid
MI0N98700Medicare PIN
MOY150000Medicare PIN
MOMA2885Medicare PIN
LA5CH88Medicare PIN
LA255463Medicare PIN
MI0N98700Medicare ID - Type Unspecified
MO506127307Medicaid
OH2206802Medicaid
MICC4797OtherMETRAHEALTH RR
IL208875Medicare ID - Type Unspecified
MO000013987Medicare ID - Type Unspecified