Provider Demographics
NPI:1912277906
Name:THOMAS J SHEWCZYK MD SC
Entity type:Organization
Organization Name:THOMAS J SHEWCZYK MD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SHEWCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-375-1580
Mailing Address - Street 1:4922 COLUMBIA RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-9188
Mailing Address - Country:US
Mailing Address - Phone:262-375-1580
Mailing Address - Fax:262-375-9452
Practice Address - Street 1:4922 COLUMBIA RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-9188
Practice Address - Country:US
Practice Address - Phone:262-375-1580
Practice Address - Fax:262-375-9452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19364261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care