Provider Demographics
NPI:1912008921
Name:VERCELLOTTI, GREGORY M (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
Last Name:VERCELLOTTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 WASHINGTON AVE SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2924
Mailing Address - Country:US
Mailing Address - Phone:612-884-0649
Mailing Address - Fax:
Practice Address - Street 1:424 HARVARD STREET SE
Practice Address - Street 2:MASONIC CANCER CENTER, FIRST FLOOR, SUITE M100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-625-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25121207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP22082OtherHEALTHPARTNERS
MN100794OtherUCARE
MN3624552OtherMEDICA - CHOICE
MN927205400Medicaid
MN090100OtherFAIRVIEW
MN3674562OtherMEDICA - PRIMARY
MN2T188VEOtherBLUE CROSS BLUE SHIELD
MN525815OtherARAZ
MN1009342OtherPREFERREDONE
MN525815OtherARAZ
MN830000176Medicare ID - Type Unspecified