Basic Information
| Provider Information | |||||||||
| NPI: | 1962438770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDD | ||||||||
| FirstName: | MYRON | ||||||||
| MiddleName: | BROOK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11608 HWY 32 NE | ||||||||
| Address2: | |||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567012700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182807062 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 SANFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186814747 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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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 | 208600000X | 2009038289 | MO | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 46083 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 014982900 | 05 | MN | MEDICAID | 375J0RE | 01 | MN | MNBS# | OTHER | 23407 | 01 | MN | NDBS# | OTHER | 43450017 | 01 | MO | BCBS | OTHER | 1862175 | 01 | MN | AMERICA'S PPO/ARAZ# | OTHER | P00033158 | 01 | MN | MEDICARE ID-TYPE UNSPECIFIED, RR MEDICARE | OTHER | 1701054 | 01 | MN | MEDICA # | OTHER | DA9021035197 | 01 | MN | PREFERRED ONE # | OTHER | 020001912 | 01 | MN | MEDICARE ID-TYPE UNSPECIFIED, MN MEDICARE # | OTHER | 12531 | 05 | MN | MEDICAID | HP39362 | 01 | MN | HEALTHPARTNERS # | OTHER |