Healthcare Provider Details

I. General information

NPI: 1871562926
Provider Name (Legal Business Name): GUSTAVE L MELLGREN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 4TH AVE SE
GLENWOOD MN
56334-1820
US

IV. Provider business mailing address

10 4TH AVE SE
GLENWOOD MN
56334-1820
US

V. Phone/Fax

Practice location:
  • Phone: 320-634-5157
  • Fax: 320-634-2244
Mailing address:
  • Phone: 320-634-5157
  • Fax: 320-634-2244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47727
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: