Basic Information
| Provider Information | |||||||||
| NPI: | 1154403764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSCH | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3433 BROADWAY ST NE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554131761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877737 | ||||||||
| FaxNumber: | 7635877069 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 WESTGATE DR | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122627800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 45071 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 220TIMO | 01 | BLUE CROSS BLUE SHIELD | OTHER | 101787000 | 05 | MN | MEDICAID | 0404654 | 01 | MEDICA | OTHER | 1671091 | 01 | AMERICAS PPO | OTHER | 170843 | 01 | UCARE MINNESOTA | OTHER | 34301100 | 05 | WI | MEDICAID | 1031978 | 01 | PREFERRED ONE | OTHER |