Healthcare Provider Details

I. General information

NPI: 1679869697
Provider Name (Legal Business Name): HANS BJELLUM, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4622 40TH AVE S
FARGO ND
58104-4394
US

IV. Provider business mailing address

6501 CITY WEST PKWY
EDEN PRAIRIE MN
55344-3248
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-6211
  • Fax:
Mailing address:
  • Phone: 952-653-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. HANS BJELLUM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 701-232-6211