Basic Information
| Provider Information | |||||||||
| NPI: | 1437231750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANVALKENBURG | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368757 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/10/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 28834 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 28834 | MN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 185845 | 01 | WA | WASHINGTONDEPTOF LABOR&IN | OTHER | 41091744413 | 05 | NE | MEDICAID | 01-05558 | 01 | MN | MEDICA | OTHER | 127860 | 01 | MN | UCAREMN | OTHER | 1476657 | 05 | TX | MEDICAID | 224008400 | 05 | MN | MEDICAID | 1015599 | 01 | MN | PREFERREDONE | OTHER | 13700 | 05 | ND | MEDICAID | 7615483 | 05 | NC | MEDICAID | 0558460 | 05 | IA | MEDICAID | 89D04VA | 01 | MN | HP30552 | OTHER |