Provider Demographics
NPI:1154403764
Name:MOSCH, FREDERICK S (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:S
Last Name:MOSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 BROADWAY ST NE
Mailing Address - Street 2:STE 300
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1761
Mailing Address - Country:US
Mailing Address - Phone:763-587-7737
Mailing Address - Fax:763-587-7069
Practice Address - Street 1:1055 WESTGATE DR
Practice Address - Street 2:STE. 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1451
Practice Address - Country:US
Practice Address - Phone:612-262-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45071207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
220TIMOOtherBLUE CROSS BLUE SHIELD
MN101787000Medicaid
0404654OtherMEDICA
1671091OtherAMERICAS PPO
170843OtherUCARE MINNESOTA
WI34301100Medicaid
1031978OtherPREFERRED ONE
0404654OtherMEDICA
MN101787000Medicaid