Provider Demographics
NPI:1407837560
Name:MELLING, CARL MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:MICHAEL
Last Name:MELLING
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 1:1555 NORTHWAY DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4913
Mailing Address - Country:US
Mailing Address - Phone:320-240-3157
Mailing Address - Fax:320-240-3143
Practice Address - Street 1:1555 NORTHWAY DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4913
Practice Address - Country:US
Practice Address - Phone:320-240-3157
Practice Address - Fax:320-240-3143
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
104099OtherMEDICA HEALTH PLANS
47A49MEOtherBLUE CROSS BLUE SHIELD
889003OtherPREFERRED ONE
600863OtherARAZ GRP AMERICA'S PPO
68793600OtherMEDICAL ASSISTANCE
938031OtherFIRST HEALTH PLAN
HP17772OtherHEALTH PARTNERS
600863OtherARAZ GRP AMERICA'S PPO
889003OtherPREFERRED ONE