Healthcare Provider Details

I. General information

NPI: 1649249764
Provider Name (Legal Business Name): MARY ANN ELIZABETH KISH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 OAKDALE AVE N SUITE 200 MAIL STOP 33500A
ROBBINSDALE MN
55422-2962
US

IV. Provider business mailing address

8100 34TH AVE S 21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 763-287-5000
  • Fax: 763-287-5055
Mailing address:
  • Phone: 952-883-5790
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number28623
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: