Healthcare Provider Details

I. General information

NPI: 1750317558
Provider Name (Legal Business Name): KAREN BETTS MIELKE MD, JD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W. BROADWAY ST
MISSOULA MT
59806-4587
US

IV. Provider business mailing address

682 STERLING ST S
MAPLEWOOD MN
55119-6783
US

V. Phone/Fax

Practice location:
  • Phone: 406-329-5776
  • Fax: 406-327-1796
Mailing address:
  • Phone: 651-735-7703
  • Fax: 651-735-3453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9533
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32700
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34991 - 20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: