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General NPI Number Information
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NPI Number | 1437305810
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Entity Type | Organization
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Legal Business Name | GERALD D. MCELLISTREM, M. D., P. A.
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Dates
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Enumeration Date | 08/17/2008
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Last Update Date | 08/17/2008
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Provider Practice Location Address
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Address Line | 443 HASKELL ST E
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City | WEST SAINT PAUL
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State | MN
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Zip | 55118-1600
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Country | US
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Telephone | 651-227-7051
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Fax |
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Provider Business Mailing Address
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Address Line | 443 HASKELL ST E
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City | WEST SAINT PAUL
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State | MN
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Zip | 55118-1600
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | GERALD D MCELLISTREM
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Credential |
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Telephone | 651-227-7051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 13266
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License Number State | MN
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