1780995803 NPI number — DR. EMILY N PRENDERGAST MD

Table of content: DR. EMILY N PRENDERGAST MD (NPI 1780995803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780995803 NPI number — DR. EMILY N PRENDERGAST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRENDERGAST
Provider First Name:
EMILY
Provider Middle Name:
N
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1780995803
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 UNIVERSITY AVE W STE 110N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-602-5311
Provider Business Mailing Address Fax Number:
651-222-6786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 E 26TH ST STE 100
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:
55404-4552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-884-6300
Provider Business Practice Location Address Fax Number:
612-884-6363
Provider Enumeration Date:
06/23/2010

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: 207V00000X , with the licence number:  61704 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: A128699 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 125-057-984 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0201X , with the licence number: 61704 , 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)