Provider Demographics
NPI:1669473674
Name:THEYERL, KAY ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KAY
Middle Name:ELLEN
Last Name:THEYERL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-996-3200
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:200 THEDA CLARK MEDICAL PLZ
Practice Address - Street 2:SUITE 240
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2721
Practice Address - Country:US
Practice Address - Phone:920-725-2070
Practice Address - Fax:920-725-4549
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46219-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34471300Medicaid
WI711290047OtherMEDICARE PTAN
WI711290047OtherMEDICARE PTAN
I03326Medicare UPIN