Provider Demographics
NPI:1104965029
Name:SWEDENBORG, THOMAS M (CRNA)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:M
Last Name:SWEDENBORG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1579
Mailing Address - Country:US
Mailing Address - Phone:231-723-0114
Mailing Address - Fax:
Practice Address - Street 1:562 1ST STREET
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-1579
Practice Address - Country:US
Practice Address - Phone:231-723-0114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704204485367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4929820Medicaid
MI4704204485OtherSTATE LICENSE NUMBER