Healthcare Provider Details

I. General information

NPI: 1770926958
Provider Name (Legal Business Name): KYLE WILLIAM YEAGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E NICOLLET BLVD STE 160
BURNSVILLE MN
55337-4588
US

IV. Provider business mailing address

85 E US HIGHWAY 6
VALPARAISO IN
46383-8947
US

V. Phone/Fax

Practice location:
  • Phone: 952-460-4000
  • Fax:
Mailing address:
  • Phone: 219-983-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01076350A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: