Provider Demographics
NPI:1801804489
Name:TEDFORD, THOMAS MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:TEDFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:TEDFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7400 FRANCE AVE S STE 107
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4738
Mailing Address - Country:US
Mailing Address - Phone:952-832-5252
Mailing Address - Fax:952-548-5254
Practice Address - Street 1:7400 FRANCE AVE S STE 107
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4738
Practice Address - Country:US
Practice Address - Phone:952-832-5252
Practice Address - Fax:952-548-5254
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30533174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN810803000Medicaid
MNE31393Medicare UPIN
MN810803000Medicaid