Healthcare Provider Details

I. General information

NPI: 1952336828
Provider Name (Legal Business Name): TABB MCCLUSKEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E LINCOLN ST
HENDRICKS MN
56136-0026
US

IV. Provider business mailing address

PO BOX 26 501 E LINCOLN ST
HENDRICKS MN
56136-0026
US

V. Phone/Fax

Practice location:
  • Phone: 507-275-3121
  • Fax: 507-275-3194
Mailing address:
  • Phone: 507-275-3121
  • Fax: 507-275-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31058
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: