Provider Demographics
NPI:1881649291
Name:FELEMOVICIUS, ISAAC (MD)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:FELEMOVICIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ISAAC
Other - Middle Name:
Other - Last Name:FELEMOVICIUS - HERMANGUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9201 W BROADWAY AVE STE 601
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-1924
Mailing Address - Country:US
Mailing Address - Phone:763-587-7900
Mailing Address - Fax:763-587-7066
Practice Address - Street 1:9825 HOSPITAL DR STE 300
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4768
Practice Address - Country:US
Practice Address - Phone:763-587-7900
Practice Address - Fax:763-494-7501
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39558208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN32584200Medicaid
MNH01201Medicare UPIN
MN280000064Medicare ID - Type Unspecified