Healthcare Provider Details

I. General information

NPI: 1629918198
Provider Name (Legal Business Name): MCKAYLA MARY VLIEM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST ST. S.W.
ROCHESTER MN
55905
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-2511
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax: 507-284-0702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36046
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: