Provider Demographics
NPI:1619954963
Name:BLAESER, MICHELLE M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:BLAESER
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 1:3800 PARK NICOLLET BLVD
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14000 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5713
Practice Address - Country:US
Practice Address - Phone:952-993-8601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37596207N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN274516000Medicaid
MN070000508Medicare ID - Type Unspecified
MNF96486Medicare UPIN