MEDICARE: MARK KOLLER

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	2084P0800X	Psychiatry Physician	31306	MN

General Provider Information

NPI Number	:	1407031032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK KOLLER

Provider Business Mailing Address
First Line	:	3400 W 66TH ST STE 375
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-2168
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 W 66TH ST STE 375
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-2168
Country	:	US
Telephone Number	:	952-926-7374
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2008
Last Update Date	:	01/02/2008

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