Basic Information
Provider Information | |||||||||
NPI: | 1275550790 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHELIMSKY | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9200 W WISCONSIN AVE | ||||||||
Address2: | DEPARTMENT OF NEUROLOGY | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532263522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4148055200 | ||||||||
FaxNumber: | 4142590469 | ||||||||
Practice Location | |||||||||
Address1: | 9200 W WISCONSIN AVE | ||||||||
Address2: | DEPARTMENT OF NEUROLOGY | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532263522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4148055200 | ||||||||
FaxNumber: | 4142590469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 11/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 35-059628 | OH | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 56546 | WI | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 741859 | 01 | OH | BUCKEYE MEDICAID | OTHER | 0646970 | 01 | OH | AETNA | OTHER | 1275550790 | 05 | WI |   | MEDICAID | 130009063 | 01 |   | MCR RR | OTHER | 000000510663 | 01 | OH | ANTHEM | OTHER | 000000221114 | 01 | OH | UNISON | OTHER | 363416 | 01 | OH | WELLCARE MEDICAID | OTHER | 0777888 | 05 | OH |   | MEDICAID | 1008507150001 | 05 | PA |   | MEDICAID | P00420562 | 01 | OH | MEDICARE RAILROAD | OTHER |