Healthcare Provider Details

I. General information

NPI: 1487731527
Provider Name (Legal Business Name): MARLIEKE VAN TYN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARLIEKE VAN TYN DAHLBERG MD

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 GRAND AVE PEDIATRIC AND YOUNG ADULT MEDICINE, PA
SAINT PAUL MN
55102-2331
US

IV. Provider business mailing address

233 GRAND AVE PEDIATRIC AND YOUNG ADULT MEDICINE, PA
SAINT PAUL MN
55102-2331
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-7806
  • Fax: 651-256-6710
Mailing address:
  • Phone: 651-227-7806
  • Fax: 651-256-6710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number42369
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number42369
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42369
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number42369
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: