Healthcare Provider Details

I. General information

NPI: 1134377989
Provider Name (Legal Business Name): MELISSA M ENSIGN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 COUNTY ROAD 120 SAINT CLOUD MEDICAL GROUP
SAINT CLOUD MN
56303-4872
US

IV. Provider business mailing address

251 COUNTY ROAD 120 SAINT CLOUD MEDICAL GROUP
SAINT CLOUD MN
56303-4872
US

V. Phone/Fax

Practice location:
  • Phone: 320-529-4731
  • Fax:
Mailing address:
  • Phone: 320-202-8949
  • Fax: 320-202-0756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53599
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: