1326150343 NPI number — DIVINE HEALTHCARE CORPORATION

Table of content: (NPI 1326150343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326150343 NPI number — DIVINE HEALTHCARE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE HEALTHCARE CORPORATION
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:
DIVINE HEALTHCARE NETWORK
Provider Other Organization Name Type Code:
3
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:
1326150343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
856 UNIVERSITY AVE W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104-4807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-665-9795
Provider Business Mailing Address Fax Number:
651-665-9796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
856 UNIVERSITY AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-4807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-665-9795
Provider Business Practice Location Address Fax Number:
651-665-9796
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OBI
Authorized Official First Name:
ISAAC
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
651-665-9795

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  205335700 , 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)

  • Identifier: 1326150343 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 181647 . This is a "U CARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 922134016 . This is a "MHP: MINNESOTA HEALTH PLA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 167251 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1Z68UN . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5900021 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 65531 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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