Provider Demographics
NPI:1811919251
Name:MCCONNON, THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:MCCONNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 EXPLORER ST
Mailing Address - Street 2:
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841-2813
Mailing Address - Country:US
Mailing Address - Phone:906-346-4924
Mailing Address - Fax:906-346-6474
Practice Address - Street 1:945 9TH ST
Practice Address - Street 2:
Practice Address - City:LAKE LINDEN
Practice Address - State:MI
Practice Address - Zip Code:49945-1100
Practice Address - Country:US
Practice Address - Phone:906-483-1030
Practice Address - Fax:906-296-0521
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044670207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4795520Medicaid
MITM044670OtherMI BCBS PIN
WI34801400Medicaid
B49174Medicare UPIN
WI34801400Medicaid