Healthcare Provider Details

I. General information

NPI: 1194793562
Provider Name (Legal Business Name): RICHARD W MASUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 3RD ST SW
PERHAM MN
56573-1108
US

IV. Provider business mailing address

3809 EWING AVE S
MINNEAPOLIS MN
55410-1051
US

V. Phone/Fax

Practice location:
  • Phone: 218-346-4500
  • Fax:
Mailing address:
  • Phone: 612-920-8226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number22204
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: