Healthcare Provider Details

I. General information

NPI: 1679593669
Provider Name (Legal Business Name): THOMAS VANSISTINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 2ND ST
NEENAH WI
54956-2883
US

IV. Provider business mailing address

PO BOX 8003
APPLETON WI
54912-8003
US

V. Phone/Fax

Practice location:
  • Phone: 920-729-3015
  • Fax: 920-729-3021
Mailing address:
  • Phone: 920-996-3298
  • Fax: 920-738-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number37255
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: