1225004625 NPI number — MANKATO CLINIC ENDOSCOPY CENTER LLC

Table of content: (NPI 1225004625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225004625 NPI number — MANKATO CLINIC ENDOSCOPY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANKATO CLINIC ENDOSCOPY CENTER 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:
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:
1225004625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 E MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 8674
Provider Business Mailing Address City Name:
MANKATO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56001-5066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-657-6944
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANKATO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56001-5066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-657-6944
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FARROW
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
507-389-8501

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1043482 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 105111 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 443100600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6800057 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 180538 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6J32MA . This is a "BLUE CROSS MN" identifier , issued by the state of ( FM ) . This identifiers is of the category "OTHER".
  • Identifier: P00225672 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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