Basic Information
| Provider Information | |||||||||
| NPI: | 1396704110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TETZLOFF | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | TETZLOFF | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | JANE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122625000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 STATE AVE | ||||||||
| Address2: | |||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550216337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073343921 | ||||||||
| FaxNumber: | 5073325298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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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 | 207Q00000X | 32768 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 304795400 | 05 | MN | MEDICAID |