1104830595 NPI number — JOHN HALVORSEN MD

Table of content: JOHN HALVORSEN MD (NPI 1104830595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104830595 NPI number — JOHN HALVORSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALVORSEN
Provider First Name:
JOHN
Provider Middle Name:
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:
1104830595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 WASHINGTON AVE SE
Provider Second Line Business Mailing Address:
UNIVERSITY OF MINNESOTA PHYSICIANS
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-884-0649
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1414 MARYLAND AVE E
Provider Second Line Business Practice Location Address:
UMPHYSICIANS PHALEN VILLAGE CLINIC
Provider Business Practice Location Address City Name:
ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-772-3461
Provider Business Practice Location Address Fax Number:
651-772-5477
Provider Enumeration Date:
07/28/2006

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: 207Q00000X , with the licence number:  20514 , 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: 025128 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 472301 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 080154707 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL01P7 . This is a "JOHN DEERE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0360893132 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7215059 . This is a "BCBS PPO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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