1144237561 NPI number — MR. M. REUBEN RICHARDSON CRNA

Table of content: MR. M. REUBEN RICHARDSON CRNA (NPI 1144237561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144237561 NPI number — MR. M. REUBEN RICHARDSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHARDSON
Provider First Name:
M. REUBEN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RICHARDSON
Provider Other First Name:
MARK
Provider Other Middle Name:
REUBEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1144237561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5425 13TH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55417-2511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-825-2986
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 VETERANS DR
Provider Second Line Business Practice Location Address:
ANESTHESIA DEPARTMENT 112A
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55417-2309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-467-4698
Provider Business Practice Location Address Fax Number:
612-727-5961
Provider Enumeration Date:
08/01/2006

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: 367500000X , with the licence number:  R093267-3 , 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)