Provider Demographics
NPI:1962438770
Name:REDD, MYRON BROOK (MD)
Entity type:Individual
Prefix:
First Name:MYRON
Middle Name:BROOK
Last Name:REDD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11608 HWY 32 NE
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-2700
Mailing Address - Country:US
Mailing Address - Phone:218-280-7062
Mailing Address - Fax:
Practice Address - Street 1:3001 SANFORD PKWY
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701
Practice Address - Country:US
Practice Address - Phone:218-681-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009038289208600000X
MN46083208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN014982900Medicaid
MN375J0REOtherMNBS#
MN23407OtherNDBS#
MO43450017OtherBCBS
MN1862175OtherAMERICA'S PPO/ARAZ#
MNP00033158OtherMEDICARE ID-TYPE UNSPECIFIED, RR MEDICARE
MN1701054OtherMEDICA #
MNDA9021035197OtherPREFERRED ONE #
MN020001912OtherMEDICARE ID-TYPE UNSPECIFIED, MN MEDICARE #
MN12531Medicaid
MNHP39362OtherHEALTHPARTNERS #
MN375J0REOtherMNBS#
MNP00033158OtherMEDICARE ID-TYPE UNSPECIFIED, RR MEDICARE
MN1862175OtherAMERICA'S PPO/ARAZ#
MN12531Medicaid