Healthcare Provider Details
I. General information
NPI: 1932134764
Provider Name (Legal Business Name): THOMAS W MAUSBACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 07/11/2006
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
2701 13TH AVE S
FARGO ND
58103-3602
US
IV. Provider business mailing address
2701 13TH AVE S
FARGO ND
58103-3602
US
V. Phone/Fax
- Phone: 701-234-3620
- Fax:
- Phone: 701-234-3620
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 3790 |
| License Number State | ND |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 592087600 |
| Identifier Type | MEDICAID |
| Identifier State | ND |
| Identifier Issuer | |
| # 2 | |
| Identifier | ND100008 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | LHS# |
| # 3 | |
| Identifier | 1201795 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MEDICA # |
| # 4 | |
| Identifier | 1201198 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MEDICA # |
| # 5 | |
| Identifier | 676635 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | AMERICA'S PPO/ARAZ # |
| # 6 | |
| Identifier | 1201202 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MEDICA # |
| # 7 | |
| Identifier | 50288MA |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MNBS # |
| # 8 | |
| Identifier | 91422MA |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MNBS # |
| # 9 | |
| Identifier | DA9011015564 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | PREFERRED ONE # |
| # 10 | |
| Identifier | 141926 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | UCARE # |
| # 11 | |
| Identifier | 21590 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | NDBS # |
| # 12 | |
| Identifier | 1201197 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MEDICA # |
| # 13 | |
| Identifier | HP19527 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | HEALTHPARTNERS # |
| # 14 | |
| Identifier | 12392 |
| Identifier Type | MEDICAID |
| Identifier State | ND |
| Identifier Issuer | |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
