Healthcare Provider Details

I. General information

NPI: 1558365106
Provider Name (Legal Business Name): THOMAS BLAIR MATHESON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 6TH AVE SW
BOWMAN ND
58623-4518
US

IV. Provider business mailing address

12 6TH AVE SW
BOWMAN ND
58623-4518
US

V. Phone/Fax

Practice location:
  • Phone: 701-523-3226
  • Fax: 701-523-7107
Mailing address:
  • Phone: 701-523-3226
  • Fax: 701-523-7107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53815
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7998
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: