Provider Demographics
NPI:1699350462
Name:MCELLISTREM, EDWARD JOSEPH
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOSEPH
Last Name:MCELLISTREM
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 1:888 CHRISTENSEN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1633
Mailing Address - Country:US
Mailing Address - Phone:651-457-1034
Mailing Address - Fax:
Practice Address - Street 1:888 CHRISTENSEN AVE
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-1633
Practice Address - Country:US
Practice Address - Phone:651-457-1034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine