Provider Demographics
NPI:1487731527
Name:VAN TYN, MARLIEKE (MD)
Entity type:Individual
Prefix:DR
First Name:MARLIEKE
Middle Name:
Last Name:VAN TYN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARLIEKE
Other - Middle Name:VAN TYN
Other - Last Name:DAHLBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:233 GRAND AVE
Mailing Address - Street 2:PEDIATRIC AND YOUNG ADULT MEDICINE, PA
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2331
Mailing Address - Country:US
Mailing Address - Phone:651-227-7806
Mailing Address - Fax:651-256-6710
Practice Address - Street 1:233 GRAND AVE
Practice Address - Street 2:PEDIATRIC AND YOUNG ADULT MEDICINE, PA
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2331
Practice Address - Country:US
Practice Address - Phone:651-227-7806
Practice Address - Fax:651-256-6710
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42369207P00000X, 207PP0204X, 208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN086670900Medicaid
WI34134900Medicaid
MN086670900Medicaid