Healthcare Provider Details

I. General information

NPI: 1811087323
Provider Name (Legal Business Name): ANTHONY A KILLEEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DELAWARE STREET SE 760 MAYO MEMORIAL BUILDING
MINNEAPOLIS MN
55455
US

IV. Provider business mailing address

420 DELAWARE ST SE MMC 609 UNIVERSITY OF MINNESOTA PHYSICIANS
MINNEAPOLIS MN
55455
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-5443
  • Fax: 612-625-1121
Mailing address:
  • Phone: 612-625-5443
  • Fax: 612-625-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number30034
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0104X
TaxonomyChemical Pathology Physician
License Number30034
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number30034
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: