MEDICARE: MR. CHARLES GLEN MICKELSON C.PED.

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	224L00000X	Pedorthist		MN

General Provider Information

NPI Number	:	1568773679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES GLEN MICKELSON C.PED.

Provider Business Mailing Address
First Line	:	423 12TH AVE. NORTH
Second Line	:
City	:	SOUTH ST. PAUL
State	:	MN
Zip	:	55075-1915
Country	:	US
Telephone Number	:	651-291-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	423 12TH AVE. NORTH
Second Line	:
City	:	SOUTH ST. PAUL
State	:	MN
Zip	:	55075-1915
Country	:	US
Telephone Number	:	651-291-7000
Fax Number	:

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

Provider Enumeration Date	:	06/24/2010
Last Update Date	:	11/09/2010

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