Healthcare Provider Details

I. General information

NPI: 1871561886
Provider Name (Legal Business Name): TED L. TRUEBLOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MAIN ST N
PIERZ MN
56364-1570
US

IV. Provider business mailing address

523 N 3RD ST
BRAINERD MN
56401-3054
US

V. Phone/Fax

Practice location:
  • Phone: 320-468-2587
  • Fax: 320-468-6219
Mailing address:
  • Phone: 218-829-2861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41752
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: