1134156359 NPI number — DR. NICOLE CHAISSON M.D.

Table of content: DR. NICOLE CHAISSON M.D. (NPI 1134156359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134156359 NPI number — DR. NICOLE CHAISSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAISSON
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1134156359
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:
2020 E 28TH ST.
Provider Second Line Business Mailing Address:
UMPHYSICIANS SMILEY'S CLINIC
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-333-0770
Provider Business Mailing Address Fax Number:
612-333-1986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 E 28TH ST.
Provider Second Line Business Practice Location Address:
UFP SMILEY'S CLINIC
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-333-0770
Provider Business Practice Location Address Fax Number:
612-333-1986
Provider Enumeration Date:
06/26/2006

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:  44929 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QA0000X , with the licence number: 44929 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0586313 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 171902 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01-19354 . This is a "MEDICA CHOICE & PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2298998 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 551T1CH . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1034699 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP39171 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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