1962493643 NPI number — EITAN MEDINI MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962493643 NPI number — EITAN MEDINI MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MEDINI

Provider First Name:

EITAN

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1962493643

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

08/10/2011

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1900 CENTRA CARE CIR #1600

Provider Second Line Business Mailing Address:

CENTRA CARE CLINIC HEALTH PLAZA / RADIATION ONCOLOGY

Provider Business Mailing Address City Name:

ST CLOUD

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

56303-5000

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

320-229-4901

Provider Business Mailing Address Fax Number:

320-229-5160

Provider First Line Business Practice Location Address:

1900 CENTRA CARE CIR #1600

Provider Second Line Business Practice Location Address:

CENTRA CARE CLINIC HEALTH PLAZA / RADIATION ONCOLOGY

Provider Business Practice Location Address City Name:

ST CLOUD

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

56303-5000

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

320-229-4901

Provider Business Practice Location Address Fax Number:

320-229-5160

Provider Enumeration Date:

11/02/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2085R0001X , with the licence number:  21866 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1027482 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
• Identifier: 512RIME . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
• Identifier: COMP . This is a "FIRST HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
• Identifier: COMP . This is a "MMSI" identifier . This identifiers is of the category "OTHER".
• Identifier: 315JOME . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
• Identifier: 978660 . This is a "ARAZ GROUP AMERICAS PPO" identifier . This identifiers is of the category "OTHER".
• Identifier: 2400101 . This is a "MEDICA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
• Identifier: 252563100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: COMP . This is a "ONE HEALTH PLAN GREAT WES" identifier . This identifiers is of the category "OTHER".
• Identifier: 127789 . This is a "U CARE" identifier . This identifiers is of the category "OTHER".
• Identifier: COMP . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".
• Identifier: HP33037 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".