NPIMap

Individual provider Active NPI

Kelly Pucillo, MD

  • Family Medicine Physician
  • Waupaca, WI
National Provider Identifier
1548200595
Registry record updated Mar 15, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
49596-020 Issued in WI
Practice address
710 Riverside Dr
Waupaca, WI 54981-1941
Phone
(715) 258-1160
NPI assigned
Jun 7, 2006
Last updated
Mar 15, 2012By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 15, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 49596-020 WI Primary

Addresses

Primary practice location

710 Riverside Dr
Waupaca, WI 54981-1941

Mailing address

710 Riverside Dr
Waupaca, WI 54981-1941
Phone (608) 829-5247

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080930000622 WI Practitioner - Family Practice 6305913583 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Medical College of Wisconsin, 2005
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Thedacare, IncorporatedGroup PAC ID 1759294887, 654 clinicians

Practice addresses (Care Compare)

710 Riverside Dr
Waupaca, WI 54981-1941
Phone (715) 256-3000

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
49596-020WIMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Thedacare, Incorporated Family Medicine CurrentSince Sep 28, 2008 Accepting new patients
Thedacare Medical Center - Berlin, Inc. Past Accepting new patients

Locations

4480 W Spencer St
Appleton, WI 54914
Phone (920) 738-4800

3 Neenah Ctr
Neenah, WI 54956
Phone (920) 454-4229

1405 Mill St
New London, WI 54961
Phone (920) 531-2000

710 Riverside Dr
Waupaca, WI 54981
Phone (715) 256-3000

800 Riverside Dr
Waupaca, WI 54981
Phone (715) 258-1000

Interoperability endpoints

  • Direct secure messaging: kpucillo15158@direct.thedacare.org

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 19

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 19

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149638400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1331769600000",
    "number": "1548200595",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "710 RIVERSIDE DR",
            "city": "WAUPACA",
            "state": "WI",
            "postal_code": "549811941",
            "telephone_number": "608-829-5247"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "710 RIVERSIDE DR",
            "city": "WAUPACA",
            "state": "WI",
            "postal_code": "549811941",
            "telephone_number": "715-258-1160"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PUCILLO",
        "first_name": "KELLY",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-06-07",
        "last_updated": "2012-03-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "49596-020",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Waupaca, WI

Sources for this page

Verify at the official NPI Registry.