Provider Demographics
NPI:1609853258
Name:RALSTON, ROGER A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:RALSTON
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 1:1601 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-8648
Mailing Address - Country:US
Mailing Address - Phone:218-326-5000
Mailing Address - Fax:
Practice Address - Street 1:1601 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-8648
Practice Address - Country:US
Practice Address - Phone:218-326-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21192207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN531282500Medicaid
MN110008634Medicare ID - Type Unspecified
MN531282500Medicaid