Provider Demographics
NPI:1841471760
Name:ARTIS, TOMMIE
Entity type:Individual
Prefix:MR
First Name:TOMMIE
Middle Name:
Last Name:ARTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 N STORY PKWY
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3622
Mailing Address - Country:US
Mailing Address - Phone:414-788-5306
Mailing Address - Fax:414-453-7660
Practice Address - Street 1:453 N STORY PKWY
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3622
Practice Address - Country:US
Practice Address - Phone:414-788-5306
Practice Address - Fax:414-453-7660
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41490200Medicaid