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General NPI Number Information
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NPI Number | 1396705083
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Entity Type | Individual
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Provider Name | RANDALL A BOSTROM MD
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Gender | Male
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Dates
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Enumeration Date | 03/25/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 331 HIGHWAY 65 S
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City | MORA
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State | MN
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Zip | 55051-1899
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Country | US
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Telephone | 320-679-1313
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Fax | 320-225-3141
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Provider Business Mailing Address
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Address Line | PO BOX 43 MR 10809
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City | MINNEAPOLIS
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State | MN
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Zip | 55440-0043
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Country | US
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Telephone | 612-262-4813
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Fax | 612-262-4194
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 30066
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License Number State | MN
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