Healthcare Provider Details

I. General information

NPI: 1790862738
Provider Name (Legal Business Name): KERRY B ACE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 SMITH AVE N
SAINT PAUL MN
55102-2346
US

IV. Provider business mailing address

800 E 28TH ST # MR 11112
MINNEAPOLIS MN
55407-3723
US

V. Phone/Fax

Practice location:
  • Phone: 651-220-6914
  • Fax:
Mailing address:
  • Phone: 612-863-6590
  • Fax: 612-863-5247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number42382
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42382
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number42382
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number42382
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: