Healthcare Provider Details

I. General information

NPI: 1487680930
Provider Name (Legal Business Name): JOHN ANKER GJEVRE SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 OAK ST
BRECKENRIDGE MN
56520-1242
US

IV. Provider business mailing address

1325 S RIVER DR
MOORHEAD MN
56560-4055
US

V. Phone/Fax

Practice location:
  • Phone: 218-643-3000
  • Fax: 218-643-7502
Mailing address:
  • Phone: 218-236-8566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number18597
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number3403
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: