Provider Demographics
NPI:1699732834
Name:CARLSON, THOMAS K (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:K
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2525 5TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1204
Mailing Address - Country:US
Mailing Address - Phone:906-786-6047
Mailing Address - Fax:906-786-0660
Practice Address - Street 1:2525 5TH AVE S
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1204
Practice Address - Country:US
Practice Address - Phone:906-786-6047
Practice Address - Fax:906-786-0660
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301068161207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0402100422OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI4198743Medicaid
MI3257840Medicaid
CG4010OtherRAILROAD GROUP
MIF72261Medicare UPIN
CG4010OtherRAILROAD GROUP
MI0402100422OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI040009981Medicare PIN