Provider Demographics
NPI:1912962838
Name:GUSHURST, THOMAS PAUL (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:PAUL
Last Name:GUSHURST
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 1:3304 COOLEY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7430
Mailing Address - Country:US
Mailing Address - Phone:269-349-2266
Mailing Address - Fax:269-349-0792
Practice Address - Street 1:3304 COOLEY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7340
Practice Address - Country:US
Practice Address - Phone:269-349-2266
Practice Address - Fax:269-349-0792
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITG054920207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M92920002OtherMEDICARE
MI1851569958OtherNPI 04/25/2008 AND AFTER
MI1912962838OtherNPI
MI0P56360002OtherMEDICARE 04/25/2008
MI100C914640OtherBCBS 04/25/2008 AND AFTER
MI1013972926Medicaid
MI104717140Medicaid
MI100C910690OtherBCBSM
MI1417961137OtherBCBSM - BRONSON
MI383309299136OtherCARESOURCE MEDICAID
MI101118OtherGREAT LAKES HEALTH PLAN
MITG054920OtherBLUE CROSS BLUE SHIELD
MI101118OtherGREAT LAKES HEALTH PLAN
MI0M92920002OtherMEDICARE
MI1013972926Medicaid
MI100013733Medicare PIN