1639340409 NPI number — MARK S MELLSTROM, MD, PA

Table of content: (NPI 1639340409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639340409 NPI number — MARK S MELLSTROM, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK S MELLSTROM, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639340409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20157 ICENIC TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55044-7708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-469-3393
Provider Business Mailing Address Fax Number:
952-469-3399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20157 ICENIC TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55044-7708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-469-3393
Provider Business Practice Location Address Fax Number:
952-469-3399
Provider Enumeration Date:
03/19/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MELLSTROM
Authorized Official First Name:
MARK
Authorized Official Middle Name:
STANLEY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
952-469-3393

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  27926 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)