Basic Information
| Provider Information | |||||||||
| NPI: | 1396711859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAMMANN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1245 15TH STREET N | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202535200 | ||||||||
| FaxNumber: | 3202032113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 15TH STREET N | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202535200 | ||||||||
| FaxNumber: | 3202032113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 10/13/2009 | ||||||||
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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 | 207Q00000X | 26764 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 016708800 | 05 | MN | MEDICAID |