Basic Information
| Provider Information | |||||||||
| NPI: | 1497839831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REALMUTO | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| Address2: | 420 DELAWARE STREET SE | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122738700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2312 S 6TH ST | ||||||||
| Address2: | SUITE F256 / 2B WEST | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122738700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2084P0804X | 24370 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 10387 | 05 | ND | MEDICAID | 909890900 | 05 | MN | MEDICAID | 15-39939 | 01 | MN | MEDICA PRIMARY | OTHER | 1009284 | 01 | MN | PREFERRED ONE | OTHER | 102824 | 01 | MN | UCARE | OTHER | 765579 | 01 | MN | ARAZ | OTHER | 15-39939 | 01 | MN | MEDICA CHOICE | OTHER | 30275300 | 05 | WI | MEDICAID | 0998823 | 05 | IA | MEDICAID | 8D934RE | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | HP22342 | 01 | MN | HEALTH PARTNERS | OTHER | 7777470 | 05 | SD | MEDICAID |