Basic Information
| Provider Information | |||||||||
| NPI: | 1679528483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDOCK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14700 28TH AVE N | ||||||||
| Address2: | SUITE 20 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554474835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635593779 | ||||||||
| FaxNumber: | 7634503986 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 1ST DR NW | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559122941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074337351 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 37817 | MN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 289073900 | 05 | MN | MEDICAID |