Provider Demographics
NPI:1104854702
Name:ELLERMANN, JUTTA (MD)
Entity Type:Individual
Prefix:DR
First Name:JUTTA
Middle Name:
Last Name:ELLERMANN
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 1:420 DELAWARE STREET SE
Mailing Address - Street 2:MMC 292 UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-3345
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE STREET SE
Practice Address - Street 2:PWB 1ST FL CLINIC 1D UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-273-6004
Practice Address - Fax:612-273-8459
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN428722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0595157Medicaid
MN1043942OtherPREFERRED ONE
MN614T7ELOtherBCBS
MN132952OtherUCARE
MN2366357OtherARAZ
MNHP56036OtherHEALTPARTNERS
MT0097104Medicaid
MN16-02032OtherMEDICA PRIMARY
MN16-03394OtherMEDICA CHOICE
WI34623400Medicaid
MNI26587Medicare UPIN
MN916407300Medicare ID - Type UnspecifiedMN MA
MN16-03394OtherMEDICA CHOICE
MN300003632Medicare ID - Type UnspecifiedMEDICARE