Healthcare Provider Details

I. General information

NPI: 1578542494
Provider Name (Legal Business Name): BRIAN P WILLIAMS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 E MAIN ST MANKATO CLINIC @ MAIN STREET
MANKATO MN
56002-8674
US

IV. Provider business mailing address

PO BOX 8674 MANKATO CLINIC LTD
MANKATO MN
56002-8674
US

V. Phone/Fax

Practice location:
  • Phone: 507-625-1811
  • Fax:
Mailing address:
  • Phone: 507-625-1811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46643
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1202900
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMEDICA
# 2
Identifier874620600
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 3
IdentifierHP42383
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerHEALTH PARTNERS
# 4
IdentifierNA2951041222
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerPREFERRED ONE
# 5
Identifier513R8WI
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerBCBS
# 6
Identifier2361648
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerAMERICAS PPO
# 7
Identifier410849339 56001 C211
Identifier TypeOTHER
Identifier State
Identifier IssuerCHAMPUS
# 8
Identifier1203326
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMEDICA
# 9
Identifier0593087
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 10
Identifier131477
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerUCARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: