Basic Information
| Provider Information | |||||||||
| NPI: | 1922058866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAHLMAN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 VILLAGE CT | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550082179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186281751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/28/2012 | ||||||||
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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 | 27317 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 870867300 | 05 | MN | MEDICAID |