1114901733 NPI number — ROBERT FRIESE OD

Table of content: ROBERT FRIESE OD (NPI 1114901733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114901733 NPI number — ROBERT FRIESE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRIESE
Provider First Name:
ROBERT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1114901733
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
PO BOX 800
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56031-4575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-238-8555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PO BOX 800
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56031-0800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-238-8555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2005

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: 207W00000X , with the licence number:  2353 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 2353 , 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: 573R3FR , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 675185 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 114854 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: MH9041028502 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-02567 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 441525600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1160887 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 573R3FR . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com