Provider Demographics
NPI:1457771271
Name:MACDONALD, ALICE (MBCHB)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4744
Mailing Address - Country:US
Mailing Address - Phone:952-993-7711
Mailing Address - Fax:
Practice Address - Street 1:8455 FLYING CLOUD DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344
Practice Address - Country:US
Practice Address - Phone:952-993-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-19
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN60815207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program