Provider Demographics
NPI:1588636427
Name:DELAGE, BRYAN SCOTT (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:SCOTT
Last Name:DELAGE
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 1:450 EASTVOLD AVE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1252
Mailing Address - Country:US
Mailing Address - Phone:320-839-6157
Mailing Address - Fax:320-839-3851
Practice Address - Street 1:450 EASTVOLD AVE
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1252
Practice Address - Country:US
Practice Address - Phone:320-839-6157
Practice Address - Fax:320-839-3851
Is Sole Proprietor?:No
Enumeration Date:2006-02-05
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34305207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNE79013Medicare UPIN