Healthcare Provider Details

I. General information

NPI: 1487735379
Provider Name (Legal Business Name): MARCINE P ELLWEIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 30TH AVE W
ALEXANDRIA MN
56308-3426
US

IV. Provider business mailing address

610 30TH AVE W
ALEXANDRIA MN
56308-3426
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 Code208000000X
TaxonomyPediatrics Physician
License Number48447
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: