MEDICARE: DR. THOMAS A CARLSON 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	207R00000X	Internal Medicine Physician		IL

General Provider Information

NPI Number	:	1780675553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS A CARLSON M.D.

Provider Business Mailing Address
First Line	:	6400 INDUSTRIAL LOOP
Second Line	:
City	:	GREENDALE
State	:	WI
Zip	:	53129-2452
Country	:	US
Telephone Number	:	414-423-4100
Fax Number	:	414-423-4134

Provider Business Practice Location Address
First Line	:	111 N WABASH AVE
Second Line	:	SUITE 1710
City	:	CHICAGO
State	:	IL
Zip	:	60602-1903
Country	:	US
Telephone Number	:	312-641-2921
Fax Number	:	312-641-6184

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	07/08/2007

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