Basic Information
| Provider Information | |||||||||
| NPI: | 1063945723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDOUGLE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | MAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SALMONSON | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | MAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8100 42ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NEW HOPE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554271107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635815700 | ||||||||
| FaxNumber: | 7635815701 | ||||||||
| Practice Location | |||||||||
| Address1: | 8100 42ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NEW HOPE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554271107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635815700 | ||||||||
| FaxNumber: | 7635815701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2017 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 68270 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.