Basic Information
| Provider Information | |||||||||
| NPI: | 1790733582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TETZLAFF | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1450 | ||||||||
| Address2: | NW0090 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554850090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002791395 | ||||||||
| FaxNumber: | 5176946441 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 EAST 21ST STREET | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053228000 | ||||||||
| FaxNumber: | 7028538505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 11/13/2008 | ||||||||
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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 | 2080P0203X | 3374 | NV | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 208000000X | 4674 | SD | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | 4674 | SD | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002016073 | 05 | NV | MEDICAID | 1790733582 | 05 | MN | MEDICAID | 6701390 | 05 | SD | MEDICAID |