1205078300 NPI number — PEDIATRIC AND YOUNG ADULT MEDICINE, PA

Table of content: (NPI 1205078300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205078300 NPI number — PEDIATRIC AND YOUNG ADULT MEDICINE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC AND YOUNG ADULT MEDICINE, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205078300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1804 7TH ST W
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55116-2300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-256-6706
Provider Business Mailing Address Fax Number:
651-256-6766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3470 WASHINGTON DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-1355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-256-6706
Provider Business Practice Location Address Fax Number:
651-256-6766
Provider Enumeration Date:
04/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JOSEPH
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
651-256-6706

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  154 , 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: 1104806165 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245210210 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1881057065 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1083694046 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1861558835 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1386991339 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245210095 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1477870921 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1912987900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1497735419 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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