Basic Information
| Provider Information | |||||||||
| NPI: | 1013996941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELLER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 | ||||||||
| Address2: | 1230 E MAIN ST | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1421 PREMIER DR | ||||||||
| Address2: | MANKATO CLINIC | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35968 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 41084933956001C107 | 01 | CHAMPUS | OTHER | 1666857 | 01 | AMERICAS PPO MN | OTHER | 789317500 | 05 | MN | MEDICAID | 0110346 | 01 | MEDICA MN | OTHER | 080083832 | 01 | RR MEDICARE | OTHER | HP25859 | 01 | HEALTH PARTNERS MN | OTHER | 115901 | 01 | UCARE MN | OTHER | 18A65PE | 01 | BCBS MN | OTHER | NA2951023850 | 01 | PREFERRED ONE MN | OTHER |