Basic Information
| Provider Information | |||||||||
| NPI: | 1881689503 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOSSEY | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4695 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | SPRING PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553849715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524427895 | ||||||||
| FaxNumber: | 9524427894 | ||||||||
| Practice Location | |||||||||
| Address1: | 4695 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | SPRING PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553849715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524427895 | ||||||||
| FaxNumber: | 9524427894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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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 | 2086S0129X | 22150 | MN | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1005202 | 01 | MN | PREFERREDONE | OTHER | 959598800 | 05 | MN | MEDICAID | 17-01333 | 01 | MN | MEDICA | OTHER | 4026961 | 01 | MN | AETNA | OTHER | 106524 | 01 | FM | HEALTH PARTERS | OTHER | 421LSP2 AND 421L13FO | 01 | MN | BCBSM | OTHER |