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NPI Code Detail

MEDICARE: ELLEN DE VRIES

MEDICARE: ELLEN DE VRIES
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
1208000000XPediatrics Physician31602MN

General Provider Information

NPI Number : 1902880735
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELLEN DE VRIES
Provider Business Mailing Address
First Line : 6465 WAYZATA BLVD
Second Line : SUITE 315
City : ST LOUIS PARK
State : MN
Zip : 55426-1728
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 14000 FAIRVIEW DR
Second Line :
City : BURNSVILLE
State : MN
Zip : 55337-5713
Country : US
Telephone Number : 952-993-8700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/05/2005
Last Update Date : 10/21/2011

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Directions to “ ELLEN DE VRIES ” Practice Location

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