Basic Information
| Provider Information | |||||||||
| NPI: | 1710181912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCANN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2629 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530834932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204515553 | ||||||||
| FaxNumber: | 9204515113 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | TWO RIVERS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542413923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207936550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 53215 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100003910 | 05 | WI | MEDICAID |