Basic Information
| Provider Information | |||||||||
| NPI: | 1104854702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLERMANN | ||||||||
| FirstName: | JUTTA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 DELAWARE STREET SE | ||||||||
| Address2: | MMC 292 UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126263345 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 516 DELAWARE STREET SE | ||||||||
| Address2: | PWB 1ST FL CLINIC 1D UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122736004 | ||||||||
| FaxNumber: | 6122738459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 42872 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0595157 | 05 | IA | MEDICAID | 1043942 | 01 | MN | PREFERRED ONE | OTHER | 614T7EL | 01 | MN | BCBS | OTHER | 132952 | 01 | MN | UCARE | OTHER | 2366357 | 01 | MN | ARAZ | OTHER | HP56036 | 01 | MN | HEALTPARTNERS | OTHER | 0097104 | 05 | MT | MEDICAID | 16-02032 | 01 | MN | MEDICA PRIMARY | OTHER | 16-03394 | 01 | MN | MEDICA CHOICE | OTHER | 34623400 | 05 | WI | MEDICAID |