Provider Demographics
NPI:1992751820
Name:BRATTLOF, BRIAN D (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:BRATTLOF
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 1:705 PLEASANT AVE S
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1440
Mailing Address - Country:US
Mailing Address - Phone:218-732-2800
Mailing Address - Fax:218-732-2857
Practice Address - Street 1:705 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1440
Practice Address - Country:US
Practice Address - Phone:218-732-2800
Practice Address - Fax:218-732-2857
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33031208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FMDA9041015604OtherPREFERRED ONE #
MN27943BROtherMNBS #
FM529297200Medicaid
MN54913BROtherMNBS #
MN20574BROtherMNBS #
FMMN200000OtherLHS/BANNERHEALTH #
MN5117OtherNDBS #
FM819328OtherAMERICA'S PPO/ARAZ #
MN10064OtherNDBS #
FM1700499OtherMEDICA #
FM1700584OtherMEDICA #
MN10475OtherNDBS #
MN18686Medicaid
FM1M789BROtherMNBS #
MN10064OtherNDBS #
FMDA9041015604OtherPREFERRED ONE #
MN5117OtherNDBS #
FM1M789BROtherMNBS #
MN10475OtherNDBS #
MN029000781Medicare ID - Type UnspecifiedMN MEDICARE #