Healthcare Provider Details

I. General information

NPI: 1679505093
Provider Name (Legal Business Name): JOSEPH MICHAEL MAYLAND D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOSEPH MICHAEL JELLISON D.O.

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARKETPOINTE DR STE 100
BLOOMINGTON MN
55435-5435
US

IV. Provider business mailing address

301 BECKER AVE SW
WILLMAR MN
56201-3302
US

V. Phone/Fax

Practice location:
  • Phone: 952-835-9880
  • Fax:
Mailing address:
  • Phone: 320-235-4543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number45578
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: