Provider Demographics
NPI:1912931411
Name:HALLBERG, JON SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:SCOTT
Last Name:HALLBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE,
Mailing Address - Street 2:MMC 381 UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-624-2622
Mailing Address - Fax:612-624-5930
Practice Address - Street 1:901 S 2ND ST STE A
Practice Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS-MILL CITY CLINIC
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-2123
Practice Address - Country:US
Practice Address - Phone:612-338-1383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN102652OtherUCARE
MN21741OtherARAZ
MN059A0HAOtherBCBS
MN1008966OtherPREFERRED ONE
MN955325800Medicaid
MNHP20043OtherHEALTHPARTNERS
MN1008966OtherPREFERRED ONE
MN080010159Medicare ID - Type UnspecifiedMEDICARE