Provider Demographics
NPI:1326226093
Name:THOMAS R. MARCINIAK
Entity type:Organization
Organization Name:THOMAS R. MARCINIAK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARCINIAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:414-546-4151
Mailing Address - Street 1:3515 S 68TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-1206
Mailing Address - Country:US
Mailing Address - Phone:414-546-4151
Mailing Address - Fax:
Practice Address - Street 1:3515 S 68TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-1206
Practice Address - Country:US
Practice Address - Phone:414-546-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI 461-25332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43217100Medicaid
WI43217100Medicaid
1288630001Medicare NSC