Provider Demographics
NPI:1497715726
Name:PELLER, THOMAS P (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
Last Name:PELLER
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 1:714 W HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6937
Mailing Address - Country:US
Mailing Address - Phone:715-830-9990
Mailing Address - Fax:715-830-9995
Practice Address - Street 1:714 W HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6937
Practice Address - Country:US
Practice Address - Phone:715-830-9990
Practice Address - Fax:715-830-9995
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34997207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32016000Medicaid
WI20340Medicare ID - Type Unspecified
F86180Medicare UPIN
WI32016000Medicaid