Provider Demographics
NPI:1558462945
Name:WAMBACH, THOMAS G (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:WAMBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 EAST 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-786-1234
Mailing Address - Fax:
Practice Address - Street 1:400 EAST 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805
Practice Address - Country:US
Practice Address - Phone:218-786-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45494208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN142300OtherUCAREMN
MNHP28713OtherHEALTHPARTNERS
MN17-00948OtherMEDICA
MN190587200Medicaid
MN1027006OtherPREFERREDONE
ND11006Medicaid
NE41091744413Medicaid
MN474S7WAOtherBCBS
MN474S7WAOtherBCBS
MN142300OtherUCAREMN