=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558365106
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS BLAIR MATHESON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2005
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 6TH AVE SW
-----------------------------------------------------
City | BOWMAN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58623-4518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-523-3226
-----------------------------------------------------
Fax | 701-523-7107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 6TH AVE SW
-----------------------------------------------------
City | BOWMAN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58623-4518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-523-3226
-----------------------------------------------------
Fax | 701-523-7107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 53815
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 7998
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------