Provider Demographics
NPI:1033135298
Name:CONLEY, JUSTIN T (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:T
Last Name:CONLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 30TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3426
Mailing Address - Country:US
Mailing Address - Phone:320-763-5123
Mailing Address - Fax:320-763-7883
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3426
Practice Address - Country:US
Practice Address - Phone:320-763-5123
Practice Address - Fax:320-763-7883
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48867208000000X
MI4301111066208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN135595OtherUCARE #
MN623E1COOtherMN BCBS #
MN27253OtherNDBCBS #
MNHP69889OtherHEALTHPARTNERS #
MN0012-0006861OtherMEDICA
MN010437100Medicaid
MN1033135298OtherPRIMEWEST HEALTHCARE
MN1203709OtherMEDICA #
MN13904Medicaid
MN13904Medicaid
MN1033135298OtherPRIMEWEST HEALTHCARE
MN6697670002Medicare NSC
MN370003436Medicare PIN