Provider Demographics
NPI:1447236062
Name:MEIGHAN, MARY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:MEIGHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1120 WAYZATA BLVD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1916
Mailing Address - Country:US
Mailing Address - Phone:952-476-6733
Mailing Address - Fax:952-476-0084
Practice Address - Street 1:1120 WAYZATA BLVD E
Practice Address - Street 2:SUITE 100
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1916
Practice Address - Country:US
Practice Address - Phone:952-476-6733
Practice Address - Fax:952-476-0084
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN34897207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN107778300Medicaid
070000645Medicare ID - Type Unspecified
E90467Medicare UPIN