Provider Demographics
NPI:1245267533
Name:REBELLA, TIFFANY L (MD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:REBELLA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:L
Other - Last Name:REBELLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
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:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:N84W16889 MENOMONEE AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2810
Practice Address - Country:US
Practice Address - Phone:262-251-7500
Practice Address - Fax:262-251-7128
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46467207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34490400Medicaid
WIP00612842OtherRR MEDICARE
WI46236-0205Medicare PIN
WIP00612842OtherRR MEDICARE
WII05756Medicare UPIN