1174541692 NPI number — JOSEPH STEPHEN MICALLEF MD

Table of content: JOSEPH STEPHEN MICALLEF MD (NPI 1174541692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174541692 NPI number — JOSEPH STEPHEN MICALLEF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICALLEF
Provider First Name:
JOSEPH
Provider Middle Name:
STEPHEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1174541692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8170 33RD AVE S
Provider Second Line Business Mailing Address:
MS21110Q
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-883-5375
Provider Business Mailing Address Fax Number:
651-653-2111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1430 HWY 96 E - MAIL STOP 32300A
Provider Second Line Business Practice Location Address:
HEALTHPARTNERS WHITE BEAR LAKE CLINIC
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55110-7693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-426-1980
Provider Business Practice Location Address Fax Number:
651-653-2111
Provider Enumeration Date:
07/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  44019 , 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)