1104801638 NPI number — DR. TIMOTHY GERARD BALDER MD

Table of content: DR. TIMOTHY GERARD BALDER MD (NPI 1104801638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104801638 NPI number — DR. TIMOTHY GERARD BALDER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALDER
Provider First Name:
TIMOTHY
Provider Middle Name:
GERARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1104801638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8170 33RD AVE S
Provider Second Line Business Mailing Address:
MS 21110Q
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4730 CHICAGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55407-3570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-967-7676
Provider Business Practice Location Address Fax Number:
612-341-1432
Provider Enumeration Date:
12/07/2005

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: 207Q00000X , with the licence number:  30056 , 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: 31430000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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