Healthcare Provider Details

I. General information

NPI: 1164512091
Provider Name (Legal Business Name): MELISSA M MESSERLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA M MOILAN MD

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BURDICK EXPY E
MINOT ND
58701-4768
US

IV. Provider business mailing address

PO BOX 5010
MINOT ND
58702-5010
US

V. Phone/Fax

Practice location:
  • Phone: 701-857-5413
  • Fax: 701-857-5028
Mailing address:
  • Phone: 701-857-5650
  • Fax: 701-857-5031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6999
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier18042
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: