Basic Information
| Provider Information | |||||||||
| NPI: | 1073834016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIELSON | ||||||||
| FirstName: | JAYME | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207632540 | ||||||||
| FaxNumber: | 3207635749 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207632540 | ||||||||
| FaxNumber: | 3207635749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2010 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 56297 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 56297 | MN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1073834016 | 01 | MN | BCBS | OTHER | 1073834016 | 05 | MN | MEDICAID | 1073834016 | 01 | MN | HEALTH PARTNERS | OTHER | FD2535550 | 01 | MN | DEA | OTHER | 1073834016 | 01 | MN | MEDICA | OTHER |