1154403764 NPI number — FREDERICK S MOSCH MD

Table of content: FREDERICK S MOSCH MD (NPI 1154403764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154403764 NPI number — FREDERICK S MOSCH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSCH
Provider First Name:
FREDERICK
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154403764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3433 BROADWAY ST NE
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55413-1761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-587-7737
Provider Business Mailing Address Fax Number:
763-587-7069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1055 WESTGATE DR
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-262-7800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  45071 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 220TIMO . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 101787000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0404654 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1671091 . This is a "AMERICAS PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 170843 . This is a "UCARE MINNESOTA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 34301100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1031978 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".




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