Basic Information
Provider Information | |||||||||
NPI: | 1902821937 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOE | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 811 2ND ST. SE | ||||||||
Address2: | SUITE A | ||||||||
City: | LITTLE FALLS | ||||||||
State: | MN | ||||||||
PostalCode: | 56345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 811 2ND ST SE STE A | ||||||||
Address2: |   | ||||||||
City: | LITTLE FALLS | ||||||||
State: | MN | ||||||||
PostalCode: | 563453505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3206317000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 07/18/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 46385 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 779460600 | 05 | MN |   | MEDICAID | 879S1MO | 01 | MN | BCBS OF MINNESOTA | OTHER | 132024C736 | 01 | MN | UCARE MINNESOTA | OTHER | 2145399 | 01 |   | AMERICA'S PPO | OTHER | 0406746 | 01 |   | MEDICA | OTHER | HP43143 | 01 |   | HEALTH PARTNERS | OTHER | NA9231041286 | 01 |   | PREFERRED ONE | OTHER | A031 | 01 | MN | TRICARE | OTHER |