Basic Information
| Provider Information | |||||||||
| NPI: | 1073564126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IPSEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53585 NOKOMIS RD | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548064272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156827133 | ||||||||
| FaxNumber: | 7156857857 | ||||||||
| Practice Location | |||||||||
| Address1: | 53585 NOKOMIS RD | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548064272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156827133 | ||||||||
| FaxNumber: | 7156857857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 07/14/2017 | ||||||||
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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 | 207Q00000X | 37146 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 32307-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080005095 | 01 | MN | MEDICARE PIN | OTHER | 220313800 | 05 | MN | MEDICAID |