Basic Information
| Provider Information | |||||||||
| NPI: | 1881780393 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOTTEN | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WASHIGNTON AVE SE | ||||||||
| Address2: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128840649 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1020 WEST BROADWAY | ||||||||
| Address2: | UMP-BROADWAY FAMILY MEDICINE | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123028200 | ||||||||
| FaxNumber: | 6123028275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 04/23/2012 | ||||||||
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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 | 30205 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 768417 | 01 | MN | ARAZ | OTHER | 01-12683 | 01 | MN | MEDICA - PRIMARY | OTHER | HP27070 | 01 | MN | HEALTHPARTNERS | OTHER | 0190027 | 01 | MN | PREFERREDONE | OTHER | 36A76WO | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 01-12683 | 01 | MN | MEDICA - CHOICE | OTHER | 109253 | 01 | MN | UCARE | OTHER | 059550 | 01 | MN | FAIRVIEW | OTHER |