Basic Information
Provider Information | |||||||||
NPI: | 1437125119 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MELANSON | ||||||||
FirstName: | TINA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 9TH NWAVE | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | SD | ||||||||
PostalCode: | 572011548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6058825455 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1001 E 21ST ST | ||||||||
Address2: | STE. 300 | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571051033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053225800 | ||||||||
FaxNumber: | 6053225801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2006 | ||||||||
LastUpdateDate: | 07/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 5105 | SD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 1706711 | 01 | SD | ARAZ/ AMERICA'S PPO | OTHER | 6630830 | 05 | SD |   | MEDICAID | 300T3ME | 01 | MN | BLUE CROSS | OTHER | 0560631 | 05 | IA |   | MEDICAID | 390008566 | 01 | SD | RR MEDICARE | OTHER | 0040703 | 01 | SD | BLUE CROSS | OTHER | 28925 | 01 | SD | SANFORD HEALTH PLAN | OTHER | 5105 | 01 | SD | DAKOTACARE | OTHER | HP38411 | 01 | SD | HEALTHPARTNERS | OTHER | 12903 | 05 | ND |   | MEDICAID | 237914 | 01 | SD | MIDLANDS CHOICE | OTHER | 406751032068 | 01 | SD | PREFERRED ONE | OTHER | 46022474344 | 05 | NE |   | MEDICAID | 300T3ME | 01 | MN | CC SYSTEMS/ BLUE PLUS | OTHER | 3100148 | 01 | SD | MEDICA | OTHER | 57105P005 | 01 | SD | WPS TRICARE | OTHER | 891490700 | 05 | MN |   | MEDICAID |