Basic Information
| Provider Information | |||||||||
| NPI: | 1730131483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELNYCHUK | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | JASON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122624813 | ||||||||
| FaxNumber: | 6122624194 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 SMITH AVE N | ||||||||
| Address2: | STE 4314A | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512418436 | ||||||||
| FaxNumber: | 6512412793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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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 | 39153 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 848215200 | 05 | MN | MEDICAID |