Basic Information
Provider Information | |||||||||
NPI: | 1912975756 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRUEBLOOD | ||||||||
FirstName: | JANELLE | ||||||||
MiddleName: | AP | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 BUNKER HILL DR | ||||||||
Address2: |   | ||||||||
City: | AITKIN | ||||||||
State: | MN | ||||||||
PostalCode: | 564311865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2189272157 | ||||||||
FaxNumber: | 2189274130 | ||||||||
Practice Location | |||||||||
Address1: | 200 BUNKER HILL DR | ||||||||
Address2: |   | ||||||||
City: | AITKIN | ||||||||
State: | MN | ||||||||
PostalCode: | 564311865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2189272157 | ||||||||
FaxNumber: | 2189274130 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2006 | ||||||||
LastUpdateDate: | 11/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 42715 | MN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 080011614 | 01 | MN | MEDICARE WPS - AITKIN CLI | OTHER | 080015848 | 01 | MN | MEDIARE WPS - GARRISON CL | OTHER | 652690000 | 05 | MN |   | MEDICAID | 080011613 | 01 | MN | MEDICARE WPS - HOSPITAL | OTHER | 080011615 | 01 | MN | MEDICARE WPS - MCGREGOR C | OTHER |