Provider Demographics
NPI:1366432015
Name:MECHELKE, KATHRYN A (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:MECHELKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-229-4917
Mailing Address - Fax:320-229-5181
Practice Address - Street 1:1900 CENTRACARE CIR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-229-4917
Practice Address - Fax:320-229-5181
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
083483100OtherMEDICAL ASSISTANCE
1328113OtherARAZ GROUP/AMERICA'S PPO
0107722OtherMEDICA HEALTH PLANS
140249OtherU-CARE
HP33397OtherHEALTH PARTNERS
1027779OtherPREFERRED ONE
2114101OtherFIRST HEALTH PLAN
49F16MEOtherBLUE CROSS BLUE SHIELD
H41668Medicare UPIN