Healthcare Provider Details

I. General information

NPI: 1558525022
Provider Name (Legal Business Name): ALMA FLORA TATUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24760 HOSPITAL DR
RED LAKE MN
56671
US

IV. Provider business mailing address

PO BOX 3144
BEMIDJI MN
56619-3144
US

V. Phone/Fax

Practice location:
  • Phone: 218-679-3912
  • Fax:
Mailing address:
  • Phone: 787-426-0682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12540
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: