Healthcare Provider Details

I. General information

NPI: 1922448018
Provider Name (Legal Business Name): THOMAS GEORGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 SHERMAN AVE E
FORT ATKINSON WI
53538-1960
US

IV. Provider business mailing address

PO BOX 249
FORT ATKINSON WI
53538-0249
US

V. Phone/Fax

Practice location:
  • Phone: 920-568-5000
  • Fax:
Mailing address:
  • Phone: 920-563-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125064028
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number21653-875
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036140741
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: