1104927169 NPI number — ELDON SODERBERG PT

Table of content: ELDON SODERBERG PT (NPI 1104927169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104927169 NPI number — ELDON SODERBERG PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SODERBERG
Provider First Name:
ELDON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1104927169
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2040 DOUGLAS DR N
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
GOLDEN VALLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55422-3944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-925-9566
Provider Business Mailing Address Fax Number:
763-544-2180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2040 DOUGLAS DR N
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
GOLDEN VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55422-3944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-925-9566
Provider Business Practice Location Address Fax Number:
763-544-2180
Provider Enumeration Date:
09/25/2006

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: 2251X0800X , with the licence number:  1821 , 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: 035J9SO . This is a "MN BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 370085200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 123593400 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 173205 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6401945 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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