Provider Demographics
NPI:1669543708
Name:HAUPTMANN, ELLEN M (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:HAUPTMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN
Mailing Address - Street 2:STE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:16935 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98177-3840
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3068612085R0202X
WAMD000285632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAHA7884OtherBLUE SHIELD #
AKMD8565Medicaid
WA0039587OtherLABOR AND INDUSTRIES #
WAUS0861762OtherAETNA SPECIALIST PIN
WA8134439Medicaid
WA000184142Medicare PIN
WA300041902OtherRAILROAD MC#
F10069Medicare UPIN