Healthcare Provider Details

I. General information

NPI: 1215931696
Provider Name (Legal Business Name): GREGORY N TJOSSEM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 5TH AVE SE
SPRING GROVE MN
55974-1318
US

IV. Provider business mailing address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

V. Phone/Fax

Practice location:
  • Phone: 608-782-7300
  • Fax:
Mailing address:
  • Phone: 608-782-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD156481
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0053297
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40179
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: