Healthcare Provider Details

I. General information

NPI: 1003115783
Provider Name (Legal Business Name): BRIAN S MYER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST # MS 11502V
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-7980
  • Fax: 651-254-7990
Mailing address:
  • Phone: 651-254-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberD82074
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: