Basic Information
| Provider Information | |||||||||
| NPI: | 1659329910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMEL | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REDMAN | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | LYN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24760 HOSPITAL DRIVE | ||||||||
| Address2: | HWY 1 | ||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566710249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | 2186790181 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 LAKE BLVD NE | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566013920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282317742 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
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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 | 208000000X | 39947 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | BH2603391 | 01 | DEA REGISTRATION | OTHER |