MEDICARE: THADDEUS STANLEY WALCZAK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	40359	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	130018102	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	792831	OTHER		AMERICAS PPO
2	31Q17WA	OTHER	MN	BLUE CROSS BLUE SHIELD
3	A011	OTHER		TRIWEST
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	41-1677590	OTHER		1ST CHOICE OF THE MIDWEST
8	HP7170	OTHER		HEALTHPARTNERS
9	01014968	OTHER		PREFERRED ONE
10	05-81578	OTHER		MEDICA
11	41-1677590	OTHER		WEA TRUST INSURANCE

General Provider Information

NPI Number	:	1538180864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THADDEUS STANLEY WALCZAK M.D.

Provider Business Mailing Address
First Line	:	5775 WAYZATA BLVD
Second Line	:	SUITE 200
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-1222
Country	:	US
Telephone Number	:	952-525-4511
Fax Number	:	952-525-1560

Provider Business Practice Location Address
First Line	:	5775 WAYZATA BLVD
Second Line	:	SUITE 200
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-1222
Country	:	US
Telephone Number	:	952-525-4511
Fax Number	:	952-525-1560

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	09/21/2011

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