Provider Demographics
NPI:1730131483
Name:MELNYCHUK, ALAN JASON (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:JASON
Last Name:MELNYCHUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:STE 4314A
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-241-8436
Practice Address - Fax:651-241-2793
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-03-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN39153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN848215200Medicaid
080004819Medicare ID - Type Unspecified
G37839Medicare UPIN