Provider Demographics
NPI:1538180864
Name:WALCZAK, THADDEUS STANLEY (MD)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:STANLEY
Last Name:WALCZAK
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Gender:M
Credentials:MD
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Mailing Address - Street 1:5775 WAYZATA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1222
Mailing Address - Country:US
Mailing Address - Phone:952-525-4511
Mailing Address - Fax:952-525-1560
Practice Address - Street 1:5775 WAYZATA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-1222
Practice Address - Country:US
Practice Address - Phone:952-525-4511
Practice Address - Fax:952-525-1560
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2011-09-21
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Provider Licenses
StateLicense IDTaxonomies
MN403592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
792831OtherAMERICAS PPO
MN31Q17WAOtherBLUE CROSS BLUE SHIELD
A011OtherTRIWEST
130018102OtherRAILROAD MEDICARE
MN338516700Medicaid
ND10088Medicaid
41-1677590Other1ST CHOICE OF THE MIDWEST
HP7170OtherHEALTHPARTNERS
01014968OtherPREFERRED ONE
05-81578OtherMEDICA
41-1677590OtherWEA TRUST INSURANCE
01014968OtherPREFERRED ONE
130018102OtherRAILROAD MEDICARE