Basic Information
| Provider Information | |||||||||
| NPI: | 1679524805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMBROSE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 E. 20TH ST. | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053221300 | ||||||||
| FaxNumber: | 6053221301 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 E. 20TH ST. | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053221300 | ||||||||
| FaxNumber: | 6053221301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 04/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 01037487A | IN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 41335 | IA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 10090 | SD | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000000247026 | 01 | IN | ANTHEM PIN | OTHER | 100357760 | 05 | IN | MEDICAID |