Provider Demographics
NPI:1306819073
Name:METCALF, DAN RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:RUSSELL
Last Name:METCALF
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 1:1615 MAPLE LANE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806
Mailing Address - Country:US
Mailing Address - Phone:715-685-5500
Mailing Address - Fax:715-682-4022
Practice Address - Street 1:1615 MAPLE LANE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806
Practice Address - Country:US
Practice Address - Phone:715-685-5500
Practice Address - Fax:715-682-4022
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47992208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN353697100Medicaid
MN020002603Medicare PIN
MN353697100Medicaid