Provider Demographics
NPI:1407082639
Name:MAUCH, EDWARD JAMES (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JAMES
Last Name:MAUCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-4370
Mailing Address - Country:US
Mailing Address - Phone:715-294-5766
Mailing Address - Fax:715-294-2943
Practice Address - Street 1:265 GRIFFIN ST E
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001
Practice Address - Country:US
Practice Address - Phone:715-268-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN53097207Q00000X
WI57240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1407082639Medicaid
1407082639OtherBCBS
P00860779OtherRAILROAD MEDICARE
01-42339OtherMEDICA
MN1407082639Medicaid