1770641227 NPI number — JENNIFER L GROSSMAN PA

Table of content: JENNIFER L GROSSMAN PA (NPI 1770641227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770641227 NPI number — JENNIFER L GROSSMAN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSSMAN
Provider First Name:
JENNIFER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

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:
1770641227
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1524 LIBERTY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAKOPEE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55379-4545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-743-5210
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2014 JEFFERSON RD
Provider Second Line Business Practice Location Address:
NORTHFIELD URGENT CARE
Provider Business Practice Location Address City Name:
NORTHFIELD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55057-3251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-664-9999
Provider Business Practice Location Address Fax Number:
507-664-3954
Provider Enumeration Date:
12/05/2006

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: 363AM0700X , with the licence number:  10216 , 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: 896493000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".