Healthcare Provider Details

I. General information

NPI: 1306231865
Provider Name (Legal Business Name): LAUREN KLEIN MRACHEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

400 STINSON BLVD FL 2 PROVIDER ENROLLMENT REV MGMT
MINNEAPOLIS MN
55413-2614
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberDR.0060107
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number68111
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: