Healthcare Provider Details

I. General information

NPI: 1689779993
Provider Name (Legal Business Name): WILLIAM D PAYNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 DELAWARE STREET SE PWB SECOND FLOOR, CLINIC 2A
MINNEAPOLIS MN
55455
US

IV. Provider business mailing address

420DELAWARE STREET SE, MMD 292 UNIVERSITY OF MINNESOTA PHYSICIANS
MINNEAPOLIS MN
55455
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-6100
  • Fax:
Mailing address:
  • Phone: 612-626-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number22417
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number22417
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: