Provider Demographics
NPI:1538147616
Name:TENGE, JACK R (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:TENGE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:11020 W PLANK CT
Practice Address - Street 2:SUITE 100
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3279
Practice Address - Country:US
Practice Address - Phone:414-256-5587
Practice Address - Fax:414-476-2976
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2015-05-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI19340207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIF18609Medicare UPIN