Basic Information
| Provider Information | |||||||||
| NPI: | 1124525779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGLSEDER | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5601 96TH AVE N STE 200 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554434505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637869543 | ||||||||
| FaxNumber: | 7637863320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2018 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207QS0010X | 72195 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.