Provider Demographics
NPI:1780603332
Name:TANKE, TIMOTHY EDWARD (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:TANKE
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 1:744 S WEBSTER AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-433-3640
Mailing Address - Fax:920-433-3705
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:2ND FL
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3640
Practice Address - Fax:920-433-3705
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36179-20207RI0011X
WI36179207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32340100Medicaid
000004Medicare Oscar/Certification
WI32340100Medicaid
WIP00759544Medicare Oscar/Certification
000042Medicare Oscar/Certification
07125-0295Medicare ID - Type Unspecified
WIP00970542Medicare Oscar/Certification
000027Medicare Oscar/Certification
000043Medicare Oscar/Certification
000078Medicare Oscar/Certification
MIOP383400027Medicare Oscar/Certification
000034Medicare Oscar/Certification
WI002150213Medicare Oscar/Certification