MEDICARE: DR. MARTIN ROBERT VON IDERSTINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NX0800X	Orthopedic Chiropractor		MN

General Provider Information

NPI Number	:	1457357626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTIN ROBERT VON IDERSTINE

Provider Business Mailing Address
First Line	:	4600 LAKE RD
Second Line	:
City	:	ROBBINSDALE
State	:	MN
Zip	:	55422-1800
Country	:	US
Telephone Number	:	763-533-6775
Fax Number	:	763-535-2850

Provider Business Practice Location Address
First Line	:	4600 LAKE RD
Second Line	:
City	:	ROBBINSDALE
State	:	MN
Zip	:	55422-1800
Country	:	US
Telephone Number	:	763-533-6775
Fax Number	:	763-535-2850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	07/08/2007

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