Basic Information
| Provider Information | |||||||||
| NPI: | 1477585719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEUDECKER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 811 2ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LITTLE FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563453559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206317000 | ||||||||
| FaxNumber: | 3206320534 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 2ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LITTLE FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563453559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206317000 | ||||||||
| FaxNumber: | 3206320534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 11/07/2012 | ||||||||
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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 | 26011 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 112332C736 | 01 | MN | UCARE MINNEOSTA | OTHER | NA9230454511 | 01 | PREFERRED ONE | OTHER | 21629 | 01 | AMERICA'S PPO | OTHER | 757703600 | 05 | MN | MEDICAID | A011 | 01 | MN | TRICARE | OTHER | HP11117 | 01 | HEALTH PARTNERS | OTHER | 0103874 | 01 | MEDICA | OTHER | 54682NE | 01 | MN | BCBS OF MINNESOTA | OTHER |