Healthcare Provider Details

I. General information

NPI: 1255452926
Provider Name (Legal Business Name): MEYSAM A KEBRIAEI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 SMITH AVE N STE 301
SAINT PAUL MN
55102-3355
US

IV. Provider business mailing address

201 E NICOLLET BLVD
BURNSVILLE MN
55337-5714
US

V. Phone/Fax

Practice location:
  • Phone: 651-220-5230
  • Fax:
Mailing address:
  • Phone: 952-892-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number5530
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: