Provider Demographics
NPI: | 1619930609 |
---|---|
Name: | MELAND, SUSAN J II (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | SUSAN |
Middle Name: | J |
Last Name: | MELAND |
Suffix: | II |
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: | 712 SOUTH CASCADE STREET |
Mailing Address - Street 2: | |
Mailing Address - City: | FERGUS FALLS |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 56537-2813 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 218-736-8000 |
Mailing Address - Fax: | 218-739-6742 |
Practice Address - Street 1: | 712 SOUTH CASCADE STREET |
Practice Address - Street 2: | |
Practice Address - City: | FERGUS FALLS |
Practice Address - State: | MN |
Practice Address - Zip Code: | 56537-2813 |
Practice Address - Country: | US |
Practice Address - Phone: | 218-739-2221 |
Practice Address - Fax: | 218-739-6742 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-10 |
Last Update Date: | 2017-02-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 41395 | 2084P0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 940814200 | Medicaid | |
MN | 01019156 | Other | PREFERREDONE |
MN | 38B84ME | Other | BLUECROSS/BLUESHIELD |
MN | 1520407 | Other | UBH |
MN | 1520407 | Other | UBH |
MN | 940814200 | Medicaid |