Provider Demographics
NPI:1609983717
Name:TYE, MICHAEL K (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:TYE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:KENNETH
Other - Last Name:TYE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-670-4000
Mailing Address - Fax:
Practice Address - Street 1:1640 E SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027
Practice Address - Country:US
Practice Address - Phone:262-670-4000
Practice Address - Fax:262-670-4451
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32538900Medicaid
WIP00941509OtherRR MEDICARE
WI32538900Medicaid
WIP00941509OtherRR MEDICARE
WI019940567Medicare PIN
WI462364799Medicare PIN