MEDICARE: DR. DOUGLAS L GERVAIS 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	208200000X	Plastic Surgery Physician	38691	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17A56GE	OTHER	MN	BLUE CROSS

General Provider Information

NPI Number	:	1801864814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS L GERVAIS MD

Provider Business Mailing Address
First Line	:	4825 OLSON MEMORIAL HWY
Second Line	:	#200
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55422
Country	:	US
Telephone Number	:	763-545-0443
Fax Number	:	763-545-2784

Provider Business Practice Location Address
First Line	:	4825 OLSON MEMORIAL HWY
Second Line	:	#200
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55422
Country	:	US
Telephone Number	:	763-545-0443
Fax Number	:	763-545-2784

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/08/2007

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