Provider Demographics
NPI:1093823130
Name:KELLY, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 NTH MAYFAIR RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-771-8228
Mailing Address - Fax:414-256-2483
Practice Address - Street 1:201 NTH MAYFAIR RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-771-8228
Practice Address - Fax:414-256-2483
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI31137207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31597200Medicaid
WI73840, 02445Medicare ID - Type Unspecified
WI31597200Medicaid