Provider Demographics
NPI:1497935290
Name:THOMAS B. HUIZENGA, M.D.,S.C.
Entity Type:Organization
Organization Name:THOMAS B. HUIZENGA, M.D.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-961-0304
Mailing Address - Street 1:2500 N MAYFAIR RD STE 500
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1415
Mailing Address - Country:US
Mailing Address - Phone:414-257-2525
Mailing Address - Fax:414-961-2061
Practice Address - Street 1:525 W RIVER WOODS PKWY STE 130
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1010
Practice Address - Country:US
Practice Address - Phone:414-961-0304
Practice Address - Fax:414-961-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49399207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34874500Medicaid
WII59887Medicare UPIN
WI000001639Medicare PIN