Basic Information
| Provider Information | |||||||||
| NPI: | 1407082639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAUCH | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 65TH AVE | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540204370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152945766 | ||||||||
| FaxNumber: | 7152942943 | ||||||||
| Practice Location | |||||||||
| Address1: | 265 GRIFFIN ST E | ||||||||
| Address2: | |||||||||
| City: | AMERY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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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 | 207Q00000X | 53097 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 57240 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1407082639 | 05 | MN | MEDICAID | 1407082639 | 01 | BCBS | OTHER | P00860779 | 01 | RAILROAD MEDICARE | OTHER | 01-42339 | 01 | MEDICA | OTHER |