Provider Demographics
NPI:1306075270
Name:CHURCHWELL, MICHAEL THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:CHURCHWELL
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:W180N8085 TOWN HALL RD
Mailing Address - Street 2:PSYCHIATRY
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3518
Mailing Address - Country:US
Mailing Address - Phone:262-251-1000
Mailing Address - Fax:
Practice Address - Street 1:6401 FRANCE AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2104
Practice Address - Country:US
Practice Address - Phone:952-924-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN698082084P0800X
IL1250564002084P0800X
WI671202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1306075270Medicaid
WI1306075270Medicaid