Healthcare Provider Details

I. General information

NPI: 1265414866
Provider Name (Legal Business Name): THOMAS SCOTT STANWYCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 GEORGE TOWNE DR SUITE B
PEWAUKEE WI
53072
US

IV. Provider business mailing address

1231 GEORGE TOWNE DR SUITE B
PEWAUKEE WI
53072
US

V. Phone/Fax

Practice location:
  • Phone: 262-746-9088
  • Fax: 262-544-6820
Mailing address:
  • Phone: 262-746-9088
  • Fax: 262-544-6820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number34171
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: