MEDICARE: DR. JON SCOTT HALLBERG M.D.

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	36295	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	102652	OTHER	MN	UCARE
2	21741	OTHER	MN	ARAZ
3	059A0HA	OTHER	MN	BCBS
4	1008966	OTHER	MN	PREFERRED ONE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	HP20043	OTHER	MN	HEALTHPARTNERS

General Provider Information

NPI Number	:	1912931411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON SCOTT HALLBERG M.D.

Provider Business Mailing Address
First Line	:	420 DELAWARE ST SE,
Second Line	:	MMC 381 UNIVERSITY OF MINNESOTA PHYSICIANS
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55455
Country	:	US
Telephone Number	:	612-624-2622
Fax Number	:	612-624-5930

Provider Business Practice Location Address
First Line	:	901 S 2ND ST STE A
Second Line	:	UNIVERSITY OF MINNESOTA PHYSICIANS-MILL CITY CLINIC
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55415-2123
Country	:	US
Telephone Number	:	612-338-1383
Fax Number	:

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	09/21/2009

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