1780644047 NPI number — BRADLEY M DOEDEN MD

Table of content: BRADLEY M DOEDEN MD (NPI 1780644047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780644047 NPI number — BRADLEY M DOEDEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOEDEN
Provider First Name:
BRADLEY
Provider Middle Name:
M
Provider Name Prefix Text:
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:
1780644047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7701 YORK AVE S
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-5845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-927-7810
Provider Business Mailing Address Fax Number:
952-927-6309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7701 YORK AVE S
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-5845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-927-7810
Provider Business Practice Location Address Fax Number:
952-927-6309
Provider Enumeration Date:
03/23/2006

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: 174400000X , with the licence number:  27594 , 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: HP13175 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0256006 . This is a "SELECT CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 20999 . This is a "AMERICAS PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 960540799002 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 410999025 . This is a "TRICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 107109C626 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3311337 . This is a "MEDICA CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 109127 . This is a "PATIENT CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3300003 . This is a "MEDICA PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 53966DO . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 616282700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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