1407834302 NPI number — FAIRVIEW EXPRESS CARE

Table of content: (NPI 1407834302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407834302 NPI number — FAIRVIEW EXPRESS CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRVIEW EXPRESS CARE
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:
INSTITUTE FOR ATHLETIC MEDICINE
Provider Other Organization Name Type Code:
3
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:
1407834302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9372
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55440-9372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-672-6724
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 39TH AVE NE
Provider Second Line Business Practice Location Address:
STE 220
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55421-4379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-789-0417
Provider Business Practice Location Address Fax Number:
612-789-0522
Provider Enumeration Date:
01/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
VP REVENUE MANAGEMENT
Authorized Official Telephone Number:
612-672-6594

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 240725600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725612 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725605 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725614 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725616 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725601 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725615 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725619 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725627 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725603 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725617 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725618 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725623 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725626 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725602 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725609 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725611 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725621 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240725625 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 207168200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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