Provider Demographics
NPI:1104825280
Name:DIVINE, ALAN (MD)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:
Last Name:DIVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S 8TH ST
Mailing Address - Street 2:PARKSIDE PROFESSIONAL BLDG., STE 600
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1208
Mailing Address - Country:US
Mailing Address - Phone:612-339-7171
Mailing Address - Fax:612-339-2885
Practice Address - Street 1:825 S 8TH ST
Practice Address - Street 2:PARKSIDE PROFESSIONAL BLDG., STE 600
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1208
Practice Address - Country:US
Practice Address - Phone:612-339-7171
Practice Address - Fax:612-339-2885
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN26378207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0401146OtherMEDICA
MN876265100Medicaid
MNHP19647OtherHEALTH PARTNERS
MNHP19647OtherHEALTH PARTNERS
MN110005638Medicare ID - Type Unspecified
MN110186494Medicare ID - Type UnspecifiedRR