Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 1496 | MN |
NPI | 1124020896 |
---|---|
Provider Name | Dr. Raymond W Mielke |
First Address | New Richland, MN 56072-0441 |
Second Address | New Richland, MN 56072 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2005 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3K036GR | BCBS PRACTICE (01) | MN |
3K037MI | BCBS INDIVIDUAL (01) | MN |
709825100 | (05) | MN |
T65868 | (02) | MN |