1841388964 NPI number — OAKDALE FAMILY PRACTICE, PC

Table of content: (NPI 1841388964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841388964 NPI number — OAKDALE FAMILY PRACTICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAKDALE FAMILY PRACTICE, PC
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:
1841388964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3366 OAKDALE AVE N
Provider Second Line Business Mailing Address:
SUITE 403
Provider Business Mailing Address City Name:
ROBBINSDALE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55422-2948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-529-9131
Provider Business Mailing Address Fax Number:
763-529-5519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3366 OAKDALE AVE N
Provider Second Line Business Practice Location Address:
SUITE 403
Provider Business Practice Location Address City Name:
ROBBINSDALE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55422-2948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-529-9131
Provider Business Practice Location Address Fax Number:
763-529-5519
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VELASCO
Authorized Official First Name:
GENE
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-529-9131

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  24D0670882 , 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: CH8589 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: NA376 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 767798700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 487659600 . This is a "DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: P153 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 06744HA . This is a "BCBS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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