Provider Demographics
NPI:1366073249
Name:GILBERG, MASON
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:GILBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 MCKNIGHT RD N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2238
Mailing Address - Country:US
Mailing Address - Phone:651-760-3236
Mailing Address - Fax:
Practice Address - Street 1:2365 MCKNIGHT RD N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-2238
Practice Address - Country:US
Practice Address - Phone:651-760-3236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1285996520Medicaid