NPIMap

Organization Active NPI

Mark S Mellstrom, MD, PA

  • Family Medicine Physician
  • Lakeville, MN
National Provider Identifier
1639340409
Registry record updated Apr 23, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
27926 Issued in MN
Legal business name
MARK S MELLSTROM, MD, PA
Practice address
20157 Icenic TRL
Lakeville, MN 55044-7708
Phone
(952) 469-3393
Fax
(952) 469-3399
NPI assigned
Mar 19, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 23, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Mark Stanley Mellstrom, M.DNPI 1346302106
Title
President
Phone
(952) 469-3393

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 27926 MN Primary

Addresses

Primary practice location

20157 Icenic TRL
Lakeville, MN 55044-7708

Mailing address

20157 Icenic TRL
Lakeville, MN 55044-7708
Phone (952) 469-3393

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1205884800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1208908800000",
    "number": "1639340409",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20157 ICENIC TRL",
            "city": "LAKEVILLE",
            "state": "MN",
            "postal_code": "550447708",
            "telephone_number": "952-469-3393",
            "fax_number": "952-469-3399"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20157 ICENIC TRL",
            "city": "LAKEVILLE",
            "state": "MN",
            "postal_code": "550447708",
            "telephone_number": "952-469-3393",
            "fax_number": "952-469-3399"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARK S MELLSTROM, MD, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-03-19",
        "last_updated": "2008-04-23",
        "status": "A",
        "authorized_official_last_name": "MELLSTROM",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "STANLEY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "952-469-3393",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "M.D"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "27926",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lakeville, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 23, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.