Healthcare Provider Details

I. General information

NPI: 1316924103
Provider Name (Legal Business Name): THOMAS M WALSH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3931 LOUISIANA AVE S
ST LOUIS PARK MN
55426
US

IV. Provider business mailing address

3931 LOUISIANA AVE S
ST LOUIS PARK MN
55426-5000
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3230
  • Fax: 952-993-1748
Mailing address:
  • Phone: 952-993-3230
  • Fax: 952-993-1748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number36753
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: