Basic Information
| Provider Information | |||||||||
| NPI: | 1992751820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRATTLOF | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 PLEASANT AVE S | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322857 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 PLEASANT AVE S | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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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 | 208600000X | 33031 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | DA9041015604 | 01 | FM | PREFERRED ONE # | OTHER | 27943BR | 01 | MN | MNBS # | OTHER | 529297200 | 05 | FM | MEDICAID | 54913BR | 01 | MN | MNBS # | OTHER | 20574BR | 01 | MN | MNBS # | OTHER | MN200000 | 01 | FM | LHS/BANNERHEALTH # | OTHER | 5117 | 01 | MN | NDBS # | OTHER | 819328 | 01 | FM | AMERICA'S PPO/ARAZ # | OTHER | 10064 | 01 | MN | NDBS # | OTHER | 1700499 | 01 | FM | MEDICA # | OTHER | 1700584 | 01 | FM | MEDICA # | OTHER | 10475 | 01 | MN | NDBS # | OTHER | 18686 | 05 | MN | MEDICAID | 1M789BR | 01 | FM | MNBS # | OTHER |