Basic Information
| Provider Information | |||||||||
| NPI: | 1194742767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AUTREY | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4222 OAKMEDE LN | ||||||||
| Address2: | |||||||||
| City: | WHITE BEAR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551107609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513988644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 69 EXCHANGE ST W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551021004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512323348 | ||||||||
| FaxNumber: | 6512323539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207R00000X | 27794 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.