Provider Demographics
NPI:1265527303
Name:AARON BLAINE MIELSTAD
Entity type:Organization
Organization Name:AARON BLAINE MIELSTAD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-935-1961
Mailing Address - Street 1:PO BOX 1170
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311
Mailing Address - Country:US
Mailing Address - Phone:651-291-0318
Mailing Address - Fax:
Practice Address - Street 1:867 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105
Practice Address - Country:US
Practice Address - Phone:651-291-0318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22-03317OtherMEDICA/GRAND AVE
MN22-03318OtherMEDICA/MINNETONKA
MN115682OtherHEALTH PARTNERS
MN059R7MJOtherBCBS
MN1028824OtherPREFERRED ONE
MN76656102882OtherPREF. ONE
MN82G74INOtherBCBS OF MN
MN502029037OtherAETNA
MN749422000Medicaid
MN502029037OtherAETNA
MN115682OtherHEALTH PARTNERS
MN749422000Medicaid