Provider Demographics
NPI:1790949626
Name:VON BORMANN, CAROLINE JANE (MB, CHB)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:JANE
Last Name:VON BORMANN
Suffix:
Gender:F
Credentials:MB, CHB
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:JANE
Other - Last Name:DAVIDGE-PITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MB, CHB
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54395207RE0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP01056932OtherMEDICARE - RAIL ROAD
MNP01056932OtherMEDICARE - RAIL ROAD