1316928351 NPI number — DAVID J TILSTRA MD

Table of content: DAVID J TILSTRA MD (NPI 1316928351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316928351 NPI number — DAVID J TILSTRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILSTRA
Provider First Name:
DAVID
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1316928351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 CENTRACARE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-654-3630
Provider Business Mailing Address Fax Number:
320-654-3657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 CENTRACARE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-654-3630
Provider Business Practice Location Address Fax Number:
320-654-3657
Provider Enumeration Date:
11/08/2005

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: 207SG0201X , with the licence number:  37920 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 37920 , 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: 1008055 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 763003 . This is a "ARAZ GROUP AMERICAS PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 51A44TI . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1200086 . This is a "MEDICA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2089340 . This is a "FIRST HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7713350 . This is a "SOUTH DAKOTA MA" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP25528 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 074814500 . This is a "MEDICAL ASSISTANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110417 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".




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