Basic Information
Provider Information | |||||||||
NPI: | 1083727200 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARGO | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 520 NW 1ST AVE | ||||||||
Address2: | STE 5 | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MN | ||||||||
PostalCode: | 557442776 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183277973 | ||||||||
FaxNumber: | 2183273245 | ||||||||
Practice Location | |||||||||
Address1: | 1542 GOLF COURSE RD | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MN | ||||||||
PostalCode: | 557449603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183277973 | ||||||||
FaxNumber: | 2183273245 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2006 | ||||||||
LastUpdateDate: | 10/19/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 39379 | MN | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 274517800 | 05 | MN |   | MEDICAID | 97B19MA | 01 | MN | BCBS | OTHER |