Provider Demographics
NPI:1669579975
Name:MARETTE, SHELLY A (MD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:A
Last Name:MARETTE
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE, MMC 292
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-273-6004
Mailing Address - Fax:
Practice Address - Street 1:500 HARVARD ST SE
Practice Address - Street 2:UNIT J2-300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0363
Practice Address - Country:US
Practice Address - Phone:612-273-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN481752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0147160Medicaid
IA0596767Medicaid
MNB681OtherCHAMPUS
MN1044925OtherPREFERRED ONE
MN16-02032OtherMEDICA PRIMARY
MNHP55471OtherHEALTH PARTNERS
MN504K5MAOtherBCBS
WI34696100Medicaid
MN135210OtherUCARE
MN718615100Medicaid
MN16-03686OtherMEDICA CHOICE
MN2380614OtherARAZ
MN16-03686OtherMEDICA CHOICE
MN718615100Medicaid