Provider Demographics
NPI:1457381576
Name:MOSLETH, MICHAEL B (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:MOSLETH
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 1:1527 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2537
Mailing Address - Country:US
Mailing Address - Phone:320-762-0399
Mailing Address - Fax:
Practice Address - Street 1:1527 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2537
Practice Address - Country:US
Practice Address - Phone:320-762-0399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23323207RP1001X
MN24099207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00663088OtherRR MEDICARE
WI30342200Medicaid
WI30342200Medicaid
MN290000749Medicare PIN
WI01994-0004Medicare PIN
WIP00663088OtherRR MEDICARE
WI68635-0210Medicare ID - Type Unspecified
WI46236-0004Medicare PIN