Healthcare Provider Details

I. General information

NPI: 1912101114
Provider Name (Legal Business Name): ANTHONY ROBERT FRATTALONE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST
SAINT PAUL MN
55101
US

IV. Provider business mailing address

8170 33RD AVE MS 21110Q
BLOOMINGTON MN
55485-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-7900
  • Fax: 651-254-7904
Mailing address:
  • Phone:
  • Fax: 651-254-7904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number10519
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number63544
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME163534
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number39
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: