Basic Information
| Provider Information | |||||||||
| NPI: | 1346285731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THACHENKARY | ||||||||
| FirstName: | TED | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629485108 | ||||||||
| FaxNumber: | 2629485109 | ||||||||
| Practice Location | |||||||||
| Address1: | 10400 75TH ST | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531427884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629485108 | ||||||||
| FaxNumber: | 2629485109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 51264 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 51264 | WI | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0200X | 51264 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00465482 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000539405 | 01 | IN | ANTHEM | OTHER | 200532220 | 05 | IN | MEDICAID |