1184973356 NPI number — NORTHMARK MEDICAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184973356 NPI number — NORTHMARK MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHMARK MEDICAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1184973356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1260 YANKEE DOODLE RD
Provider Second Line Business Mailing Address:
# 202
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55121-2201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-888-2613
Provider Business Mailing Address Fax Number:
651-846-6777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1260 YANKEE DOODLE RD
Provider Second Line Business Practice Location Address:
# 202
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55121-2201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-888-2613
Provider Business Practice Location Address Fax Number:
651-846-6777
Provider Enumeration Date:
09/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HAGLIND
Authorized Official First Name:
D
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
651-888-2613

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  000828233 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 000828233 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000828233 . This is a "PEDORTHIST" identifier . This identifiers is of the category "OTHER".




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