Healthcare Provider Details

I. General information

NPI: 1841279197
Provider Name (Legal Business Name): MICHAEL THOMAS ECKSTROM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2006
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W FOUNTAIN ST
ALBERT LEA MN
56007-2437
US

IV. Provider business mailing address

72099 WINEGLASS RD
ALBERT LEA MN
56007-5579
US

V. Phone/Fax

Practice location:
  • Phone: 507-373-2384
  • Fax:
Mailing address:
  • Phone: 507-377-2776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number43291
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: