Healthcare Provider Details

I. General information

NPI: 1568489003
Provider Name (Legal Business Name): THOMAS J MORAGHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 01/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 S 6TH ST
BRAINERD MN
56401-4529
US

IV. Provider business mailing address

523 N 3RD ST
BRAINERD MN
56401-3054
US

V. Phone/Fax

Practice location:
  • Phone: 218-828-7100
  • Fax: 218-828-7194
Mailing address:
  • Phone: 218-829-2861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number9857
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number33597
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: