Provider Demographics
NPI:1780675553
Name:CARLSON, THOMAS A (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-423-4100
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:111 N WABASH AVE
Practice Address - Street 2:SUITE 1710
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1903
Practice Address - Country:US
Practice Address - Phone:312-641-2921
Practice Address - Fax:312-641-6184
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL484551Medicare ID - Type Unspecified
ILD13353Medicare UPIN