=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760462352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS J. KNUTSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2006
-----------------------------------------------------
Last Update Date | 03/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 1ST ST
-----------------------------------------------------
City | OCONTO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54153-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-835-1144
-----------------------------------------------------
Fax | 920-835-1145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 1ST ST
-----------------------------------------------------
City | OCONTO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54153-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-835-1144
-----------------------------------------------------
Fax | 920-835-1145
-----------------------------------------------------
=====================================================
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 | 25152
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------