Provider Demographics
NPI:1912974148
Name:MOORHEAD, IAN MCKELVEY (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MCKELVEY
Last Name:MOORHEAD
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 1:5435 FELTL RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7983
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:952-857-1554
Practice Address - Street 1:550 OSBORNE RD NE
Practice Address - Street 2:UNITY HOSPITAL
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432
Practice Address - Country:US
Practice Address - Phone:763-236-4144
Practice Address - Fax:763-236-4900
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27626207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN27626OtherMN MEDICAL LICENSE
MN024888600Medicaid
930000116Medicare ID - Type Unspecified
MN024888600Medicaid