1679532022 NPI number — THOMAS WILLIAM LAEDTKE MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679532022 NPI number — THOMAS WILLIAM LAEDTKE MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

LAEDTKE

Provider First Name:

THOMAS

Provider Middle Name:

WILLIAM

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1679532022

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/12/2018

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

7701 YORK AVE S

Provider Second Line Business Mailing Address:

SUITE 180

Provider Business Mailing Address City Name:

EDINA

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

55435-5845

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

952-927-7810

Provider Business Mailing Address Fax Number:

952-927-6309

Provider First Line Business Practice Location Address:

7701 YORK AVE S

Provider Second Line Business Practice Location Address:

SUITE 180

Provider Business Practice Location Address City Name:

EDINA

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

55435

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

952-927-7810

Provider Business Practice Location Address Fax Number:

952-927-6309

Provider Enumeration Date:

03/22/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RE0101X , with the licence number:  35437 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 3300001 . This is a "MEDICA CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 658775 . This is a "AMERICAS PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 52A92LA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 106122 . This is a "PATIENT CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 0256006 . This is a "SELECT CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: HP22302 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 119367C626 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 3300003 . This is a "MEDICA PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 960541013563 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 410999025 . This is a "TRICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 894720100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".