Provider Demographics
NPI:1982601647
Name:HALSTROM, MARK RANDY (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RANDY
Last Name:HALSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-0296
Mailing Address - Country:US
Mailing Address - Phone:320-251-2600
Mailing Address - Fax:320-251-4763
Practice Address - Street 1:100 2ND ST S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-1977
Practice Address - Country:US
Practice Address - Phone:320-251-2600
Practice Address - Fax:320-251-4763
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN339524300Medicaid
MN169318P539OtherUCARE
MNHP30911OtherHEALTH PARTNERS
MN41D31HAOtherBLUE CROSS BLUE SHIELD
MNMR143-104661OtherPREFERRED ONE
MN01-05807OtherMEDICA
MN031216004OtherPRIME WEST
MN010000253Medicare ID - Type Unspecified
MN339524300Medicaid