Provider Demographics
NPI:1013996941
Name:PELLER, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:PELLER
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:PO BOX 8674
Mailing Address - Street 2:1230 E MAIN ST
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1421 PREMIER DR
Practice Address - Street 2:MANKATO CLINIC
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
41084933956001C107OtherCHAMPUS
1666857OtherAMERICAS PPO MN
MN789317500Medicaid
0110346OtherMEDICA MN
080083832OtherRR MEDICARE
HP25859OtherHEALTH PARTNERS MN
115901OtherUCARE MN
18A65PEOtherBCBS MN
NA2951023850OtherPREFERRED ONE MN
0110346OtherMEDICA MN
MN080004399Medicare ID - Type Unspecified