Basic Information
| Provider Information | |||||||||
| NPI: | 1477896132 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | THIESSEN | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | PO BOX 26099 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 9200 W WISCONSIN AVE | ||||||||
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| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148057433 | ||||||||
| FaxNumber: | 4148057499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2013 | ||||||||
| LastUpdateDate: | 08/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 63390 | WI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XP3100X | 63390 | WI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1477896132 | 05 | WI | MEDICAID |