=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982711214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. GARY L. FISCHLER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 VETERANS DR MAIL CODE 116B
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55417-2309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-333-3825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 825 S 8TH ST STE 604
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55404-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-333-3825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | LP0722
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------