Basic Information
| Provider Information | |||||||||
| NPI: | 1881684546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAUNU | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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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 | 208600000X | 44007 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2114153 | 01 | FIRST HEALTH PLAN | OTHER | 1027346 | 01 | PREFERRED ONE | OTHER | 43F36MA | 01 | BLUE CROSS BLUE SHIELD | OTHER | 1285221 | 01 | ARAZ GROUP AMERICAS PPO | OTHER | 986426100 | 01 | MEDICAL ASSISTANCE | OTHER | 151703 | 01 | U CARE | OTHER | C11369 | 01 | RR MEDICARE | OTHER | 020049623 | 01 | RR MEDICARE | OTHER | 1700538 | 01 | MEDICA HEALTH PLANS | OTHER |