MEDICARE: THRESIAMMA AUGUSTINE JOSEPH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	32036	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1201379	OTHER	MN	MEDICA
2	299L3J0	OTHER	MN	BLUE CROSS BLUE SHEILD
3	CP9090199004	OTHER	MN	PREFERRED ONE
4	1203070	OTHER	MN	MEDICA

General Provider Information

NPI Number	:	1144214107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THRESIAMMA AUGUSTINE JOSEPH MD

Provider Business Mailing Address
First Line	:	3585 LEXINGTON AVE N
Second Line	:	STE 350
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-8064
Country	:	US
Telephone Number	:	651-251-5280
Fax Number	:	651-251-5282

Provider Business Practice Location Address
First Line	:	3585 LEXINGTON AVE N
Second Line	:	STE 350
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-8064
Country	:	US
Telephone Number	:	651-484-3942
Fax Number	:	651-787-0519

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/08/2007

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