MEDICARE: RANDALL S. VOLLERTSEN MD. INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RR0500X	Rheumatology Physician	22501	MN

General Provider Information

NPI Number	:	1396818613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDALL S. VOLLERTSEN MD. INC

Provider Business Mailing Address
First Line	:	4729 COUNTY ROAD 101
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-2634
Country	:	US
Telephone Number	:	952-974-3200
Fax Number	:	952-974-3201

Provider Business Practice Location Address
First Line	:	4729 COUNTY ROAD 101
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-2634
Country	:	US
Telephone Number	:	952-974-3200
Fax Number	:	952-974-3201

Authorized Official
Title or Position	:	MANAGER
Name	:	KELLY MUCHOW
Credential	:
Telephone Number	:	952-974-3200

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	08/22/2020

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