MEDICARE: DR. THOMAS RICE WILLETT D.O.

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	207Q00000X	Family Medicine Physician	17659	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	391253020	OTHER	WI	TAX IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	391253020013	OTHER	WI	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1902806243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS RICE WILLETT D.O.

Provider Business Mailing Address
First Line	:	PO BOX 429
Second Line	:	N6250 BUSSE DRIVE
City	:	GREEN LAKE
State	:	WI
Zip	:	54941-0429
Country	:	US
Telephone Number	:	920-294-3444
Fax Number	:	920-294-6660

Provider Business Practice Location Address
First Line	:	N6205 BUSSE RD
Second Line	:
City	:	GREEN LAKE
State	:	WI
Zip	:	54941-8500
Country	:	US
Telephone Number	:	920-294-3444
Fax Number	:	920-294-6660

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	12/31/2009

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