Healthcare Provider Details

I. General information

NPI: 1629396619
Provider Name (Legal Business Name): THOMAS JENNINGS MAUST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD PARK NICOLLET CLINIC
ST. LOUIS PARK MN
55426
US

IV. Provider business mailing address

PO BOX 9104
MINNEAPOLIS MN
55480-9104
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3246
  • Fax: 952-993-3010
Mailing address:
  • Phone: 952-993-3246
  • Fax: 952-993-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number55118
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: