=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487699104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS MICHAEL BODEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2006
-----------------------------------------------------
Last Update Date | 03/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 TRIQ TA'TAHT L-IRDUM STA. MARIA EST.
-----------------------------------------------------
City | MELLIEHA
-----------------------------------------------------
State | NOT APPLICABLE
-----------------------------------------------------
Zip | MLH 2747
-----------------------------------------------------
Country | MT
-----------------------------------------------------
Telephone | 952-595-1242
-----------------------------------------------------
Fax | 952-942-3361
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11995 SINGLETREE LN SUITE 500
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55344-5347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-595-1242
-----------------------------------------------------
Fax | 952-942-3361
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 46526
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------