Provider Demographics
NPI:1477598985
Name:REST, ELLEN B (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
Last Name:REST
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 1:7205 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3134
Mailing Address - Country:US
Mailing Address - Phone:763-571-4000
Mailing Address - Fax:763-571-7202
Practice Address - Street 1:7205 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3134
Practice Address - Country:US
Practice Address - Phone:763-571-4000
Practice Address - Fax:763-571-7202
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34663174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN708078600Medicaid
MNE37655Medicare UPIN