Provider Demographics
NPI:1417040189
Name:RADKE, MICHELLE M (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:RADKE
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 1:1711 GOLD DRIVE SOUTH SUITE 160
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-234-9400
Mailing Address - Fax:701-234-9401
Practice Address - Street 1:1711 GOLD DRIVE SOUTH SUITE 160
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-234-9400
Practice Address - Fax:701-234-9401
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND8452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDG78902Medicare UPIN
ND22038Medicare ID - Type UnspecifiedMEDICARE