Healthcare Provider Details

I. General information

NPI: 1467454876
Provider Name (Legal Business Name): BRIAN T EBELING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9358 ENSIGN AVE S
BLOOMINGTON MN
55438-1455
US

IV. Provider business mailing address

7801 EAST BUSH LAKE RD STE 300
BLOOMINGTON MN
55439-3114
US

V. Phone/Fax

Practice location:
  • Phone: 952-985-8500
  • Fax: 952-985-8599
Mailing address:
  • Phone: 952-985-8911
  • Fax: 952-985-8999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20228
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: