Provider Demographics
NPI:1619932878
Name:SCRENOCK, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:SCRENOCK
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:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:OSSEO
Mailing Address - State:WI
Mailing Address - Zip Code:54758
Mailing Address - Country:US
Mailing Address - Phone:715-597-6767
Mailing Address - Fax:715-597-2819
Practice Address - Street 1:12830 COX LANE
Practice Address - Street 2:
Practice Address - City:OSSEO
Practice Address - State:WI
Practice Address - Zip Code:54758
Practice Address - Country:US
Practice Address - Phone:715-597-6767
Practice Address - Fax:715-597-2819
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17180208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31064100Medicaid
WI31064100Medicaid
000062024Medicare ID - Type Unspecified