Basic Information
| Provider Information | |||||||||
| NPI: | 1033135298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONLEY | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635123 | ||||||||
| FaxNumber: | 3207637883 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635123 | ||||||||
| FaxNumber: | 3207637883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 48867 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 4301111066 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 135595 | 01 | MN | UCARE # | OTHER | 623E1CO | 01 | MN | MN BCBS # | OTHER | 27253 | 01 | MN | NDBCBS # | OTHER | HP69889 | 01 | MN | HEALTHPARTNERS # | OTHER | 0012-0006861 | 01 | MN | MEDICA | OTHER | 010437100 | 05 | MN | MEDICAID | 1033135298 | 01 | MN | PRIMEWEST HEALTHCARE | OTHER | 1203709 | 01 | MN | MEDICA # | OTHER | 13904 | 05 | MN | MEDICAID |