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NPI Code Detail

MEDICARE: MATTHEW LEE MALLINGER BS, ATC, OTC

MEDICARE: MATTHEW LEE MALLINGER BS, ATC, OTC
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
12255A2300XAthletic Trainer2000027256MN

General Provider Information

NPI Number : 1851837389
Entity Type Code : Individual
Provider Name (Legal Business Name) : MATTHEW LEE MALLINGER BS, ATC, OTC
Provider Business Mailing Address
First Line : 8100 W 78TH ST STE 230
Second Line :
City : EDINA
State : MN
Zip : 55439-2570
Country : US
Telephone Number : 952-946-9777
Fax Number : 952-946-9888
Provider Business Practice Location Address
First Line : 2805 CAMPUS DR STE 465
Second Line :
City : PLYMOUTH
State : MN
Zip : 55441-2680
Country : US
Telephone Number : 952-946-9777
Fax Number : 952-946-9888
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/08/2017
Last Update Date : 04/19/2022

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