Provider Demographics
NPI:1265414866
Name:STANWYCK, THOMAS SCOTT (MD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:SCOTT
Last Name:STANWYCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1231 GEORGE TOWNE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072
Mailing Address - Country:US
Mailing Address - Phone:262-746-9088
Mailing Address - Fax:262-544-6820
Practice Address - Street 1:1231 GEORGE TOWNE DR
Practice Address - Street 2:SUITE B
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072
Practice Address - Country:US
Practice Address - Phone:262-746-9088
Practice Address - Fax:262-544-6820
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34171207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31980400Medicaid
WI001568200Medicare ID - Type Unspecified
WIE36072Medicare UPIN