MEDICARE: BRIAN T EBELING MD

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	207Q00000X	Family Medicine Physician	20228	MN

General Provider Information

NPI Number	:	1467454876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN T EBELING MD

Provider Business Mailing Address
First Line	:	7801 EAST BUSH LAKE RD
Second Line	:	STE 300
City	:	BLOOMINGTON
State	:	MN
Zip	:	55439-3114
Country	:	US
Telephone Number	:	952-985-8911
Fax Number	:	952-985-8999

Provider Business Practice Location Address
First Line	:	9358 ENSIGN AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55438-1455
Country	:	US
Telephone Number	:	952-985-8500
Fax Number	:	952-985-8599

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	07/08/2007

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