1063499499 NPI number — GERALD PATRICK CRIMMINS PSYD CP

Table of content: GERALD PATRICK CRIMMINS PSYD CP (NPI 1063499499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063499499 NPI number — GERALD PATRICK CRIMMINS PSYD CP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRIMMINS
Provider First Name:
GERALD
Provider Middle Name:
PATRICK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD CP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063499499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8823 JASMINE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN PRAIRIE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-200-7796
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 UNIVERSITY AVE W
Provider Second Line Business Practice Location Address:
STE 229N
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-645-3115
Provider Business Practice Location Address Fax Number:
651-645-2752
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP4454 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 510R7CR . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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