Active NPI
Glenn Leroy Detlefsen, M.D.
- Family Medicine Physician
- Rosemount, MN
National Provider Identifier
1013052554
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 26214
- Practice address
- 15120 Chippendale Ave W
Rosemount, MN 55068-1796 - Phone
- (651) 423-4114
- NPI assigned
- Feb 21, 2007
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 26214 | MN | Primary |
Addresses
Primary practice location
15120 Chippendale Ave W
Rosemount, MN 55068-1796
Mailing address
15120 Chippendale Ave W
Rosemount, MN 55068-1796
Phone (651) 423-4114
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
- Opted out of Medicare
- Previously, effective Aug 8, 2016 through Aug 8, 2026
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 26214 | MN | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172016000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1013052554",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "15120 CHIPPENDALE AVE W",
"city": "ROSEMOUNT",
"state": "MN",
"postal_code": "550681796",
"telephone_number": "651-423-4114"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "15120 CHIPPENDALE AVE W",
"city": "ROSEMOUNT",
"state": "MN",
"postal_code": "550681796",
"telephone_number": "651-423-4114"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DETLEFSEN",
"first_name": "GLENN",
"middle_name": "LEROY",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-02-21",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "MN",
"license": "26214",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Rosemount, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.