Provider Demographics
NPI:1215908876
Name:BAUMGARTNER, TOM L JR (MPT)
Entity type:Individual
Prefix:MR
First Name:TOM
Middle Name:L
Last Name:BAUMGARTNER
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 31ST AVE S STE 104
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4557
Mailing Address - Country:US
Mailing Address - Phone:701-451-9417
Mailing Address - Fax:770-129-8006
Practice Address - Street 1:4450 31ST AVE S STE 104
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4557
Practice Address - Country:US
Practice Address - Phone:701-451-9417
Practice Address - Fax:701-298-0066
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5808208100000X
ND1022208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51317Medicaid
ND51317Medicaid