Basic Information
| Provider Information | |||||||||
| NPI: | 1548590896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLWANGER | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3311 COUNTY RD 101 | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524056853 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3311 COUNTY RD 101 | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524056853 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2010 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 5310 | MN | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 1548590896 | 01 | MN | BCBS | OTHER |