Provider Demographics
NPI:1538116595
Name:IBACH, THOMAS JERRY (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JERRY
Last Name:IBACH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7595 ANAGRAM DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7399
Mailing Address - Country:US
Mailing Address - Phone:612-573-2200
Mailing Address - Fax:612-573-2274
Practice Address - Street 1:7595 ANAGRAM DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7399
Practice Address - Country:US
Practice Address - Phone:612-573-2200
Practice Address - Fax:612-573-2274
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2022-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN336942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN300032803OtherRAILROAD MEDICAR WI
MN9F048IBOtherBLUE CROSS
MN100494OtherUCARE
MN1025324OtherPREFERRED ONE
IA1272971Medicaid
MN8734132OtherDAKOTA CARE
MN883505500Medicaid
MN22833OtherAMERICA'S PPO
MN298G3IBOtherBLUE CROSS
WI34402300Medicaid
MNHP13581OtherHEALTHPARTNERS
MN253015OtherMIDLANDS CHOICE INC
MN300085351OtherRAILROAD MEDICARE MN
WI34402300Medicaid
MN300002955Medicare PIN
WI004204070Medicare PIN
MNHP13581OtherHEALTHPARTNERS
MN253015OtherMIDLANDS CHOICE INC
MNE03966Medicare UPIN