Basic Information
| Provider Information | |||||||||
| NPI: | 1487731527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN TYN | ||||||||
| FirstName: | MARLIEKE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAHLBERG | ||||||||
| OtherFirstName: | MARLIEKE | ||||||||
| OtherMiddleName: | VAN TYN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 233 GRAND AVE | ||||||||
| Address2: | PEDIATRIC AND YOUNG ADULT MEDICINE, PA | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512277806 | ||||||||
| FaxNumber: | 6512566710 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 GRAND AVE | ||||||||
| Address2: | PEDIATRIC AND YOUNG ADULT MEDICINE, PA | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512277806 | ||||||||
| FaxNumber: | 6512566710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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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 | 207P00000X | 42369 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PP0204X | 42369 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 208000000X | 42369 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 42369 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 086670900 | 05 | MN | MEDICAID | 34134900 | 05 | WI | MEDICAID |