Healthcare Provider Details

I. General information

NPI: 1982684395
Provider Name (Legal Business Name): JOHN W EMBLOM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 30TH AVENUE WEST ALEXANDRIA CLINIC
ALEXANDRIA MN
56308
US

IV. Provider business mailing address

610 30TH AVENUE WEST ALEXANDRIA CLINIC
ALEXANDRIA MN
56308
US

V. Phone/Fax

Practice location:
  • Phone: 320-763-5123
  • Fax: 320-763-7883
Mailing address:
  • Phone: 320-763-5123
  • Fax: 320-763-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27767
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: