Provider Demographics
NPI:1649675869
Name:ELMI, ISSE MOHAMED
Entity type:Individual
Prefix:MR
First Name:ISSE
Middle Name:MOHAMED
Last Name:ELMI
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ISSE
Other - Middle Name:MOHAMED
Other - Last Name:ELMI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3201 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3202
Mailing Address - Country:US
Mailing Address - Phone:612-245-0470
Mailing Address - Fax:
Practice Address - Street 1:3201 2ND AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3202
Practice Address - Country:US
Practice Address - Phone:612-245-0470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization