Provider Demographics
NPI:1073527651
Name:LOE, BRIELLE A (MD)
Entity Type:Individual
Prefix:
First Name:BRIELLE
Middle Name:A
Last Name:LOE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CONAN STREET
Mailing Address - Street 2:ESSENTIA HEALTH ELY CLINIC
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1145
Mailing Address - Country:US
Mailing Address - Phone:218-365-7900
Mailing Address - Fax:
Practice Address - Street 1:300 WEST CONAN ST.
Practice Address - Street 2:DULUTH CLINIC-ELY
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:56636
Practice Address - Country:US
Practice Address - Phone:218-365-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-25352OtherMEDICA
MN153H3LOOtherBCBSMN
MN464132000Medicaid
P00440552OtherRR MEDICARE PTAN
MNI58917Medicare UPIN
MN080015222Medicare ID - Type Unspecified