Active NPI
Mark Koller
- Psychiatry Physician
- Edina, MN
National Provider Identifier
1407031032
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- 31306
- Practice address
- 3400 W 66TH St Ste 375
Edina, MN 55435-2168 - Phone
- (952) 926-7374
- NPI assigned
- Jan 2, 2008
- 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 |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 31306 | MN | Primary |
Addresses
Primary practice location
3400 W 66TH St Ste 375
Edina, MN 55435-2168
Mailing address
3400 W 66TH St Ste 375
Edina, MN 55435-2168
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
- Yes, effective Jan 4, 2014 through Jan 4, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 31306 | MN | MD | Psychiatry Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1199232000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1199232000000",
"number": "1407031032",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3400 W 66TH ST STE 375",
"city": "EDINA",
"state": "MN",
"postal_code": "554352168"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3400 W 66TH ST STE 375",
"city": "EDINA",
"state": "MN",
"postal_code": "554352168",
"telephone_number": "952-926-7374"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KOLLER",
"first_name": "MARK",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2008-01-02",
"last_updated": "2008-01-02",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "MN",
"license": "31306",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Edina, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 2, 2008; 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.