1144880824 NPI number — DOMINIC TOMCZYK

Table of content: DOMINIC TOMCZYK (NPI 1144880824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144880824 NPI number — DOMINIC TOMCZYK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOMCZYK
Provider First Name:
DOMINIC
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144880824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3301 W FOREST HOME AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53215-2843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-389-2338
Provider Business Mailing Address Fax Number:
414-385-8987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N84W16889 MENOMONEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENOMONEE FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-251-7500
Provider Business Practice Location Address Fax Number:
262-532-1396
Provider Enumeration Date:
06/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  14650-024 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 14650-024 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100089546 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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