Healthcare Provider Details

I. General information

NPI: 1316947724
Provider Name (Legal Business Name): MICHELLE AUDREY MULTZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 SILLS RD BUILDING 18
EAST PATCHOGUE NY
11772-4869
US

IV. Provider business mailing address

11995 SINGLETREE LN SUITE 500
EDEN PRAIRIE MN
55344-5347
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 952-942-3361
Mailing address:
  • Phone: 952-595-1100
  • Fax: 952-942-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number175921
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: