Provider Demographics
NPI:1346285731
Name:THACHENKARY, TED G (MD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:G
Last Name:THACHENKARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:262-948-5108
Mailing Address - Fax:262-948-5109
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7884
Practice Address - Country:US
Practice Address - Phone:262-948-5108
Practice Address - Fax:262-948-5109
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51264207R00000X, 208M00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00465482OtherRAILROAD MEDICARE
IN000000539405OtherANTHEM
IN200532220Medicaid
IN473060U8Medicare ID - Type Unspecified
IN070860CCCCMedicare PIN
IN070880SMedicare PIN
IN000000539405OtherANTHEM