Provider Demographics
NPI:1841304359
Name:PALLER, MARK S (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:PALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE,
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-6100
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE STREET SE, PWB, CLINIC 2A
Practice Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27179207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2T173PAOtherBLUECROSS BLUESHIELD
WI30713400Medicaid
MN168568600Medicaid
31-00005OtherMEDICA - PRIMARY
MT0051986Medicaid
768290OtherARAZ
IA0500553Medicaid
1009263OtherPREFERREDONE
101500OtherUCARE
HP22172OtherHEALTHPARTNERS
31-24565OtherMEDICA - CHOICE
31-00005OtherMEDICA - PRIMARY
MT0051986Medicaid
MN168568600Medicaid