Provider Demographics
NPI:1700091592
Name:LITELL, JOHN M (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:LITELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-863-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-4762
Practice Address - Fax:612-863-8425
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021480207P00000X
MN51749207P00000X, 207RC0200X, 207RC0200X
PAOS014414207P00000X
PAOT011680207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MN810000265Medicare PIN
IAENROLLEDMedicaid