1326290727 NPI number — BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.

Table of content: (NPI 1326290727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326290727 NPI number — BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUESTONE ORAL AND MAXILLOFACIAL SURGERY, P.A.
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:
1326290727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
324 W SUPERIOR ST
Provider Second Line Business Mailing Address:
SUITE 720
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55802-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-727-8994
Provider Business Mailing Address Fax Number:
218-727-8995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 CLOQUET AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOQUET
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55720-1948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-879-3761
Provider Business Practice Location Address Fax Number:
218-879-6057
Provider Enumeration Date:
10/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SOUTHWORTH
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
DIANE
Authorized Official Title or Position:
BUSINESS MANAGAER
Authorized Official Telephone Number:
218-727-8994

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , 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: 166644400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DB2954 . This is a "RAILROAD MEDICAL GROUP#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01630538 . This is a "UNITED CONCORDIA (CLOUQET)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: U12947 . This is a "UPIN#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01630541 . This is a "UNITED CONCORDIA (DULUTH)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6B297JE . This is a "BLUE CROSS/BLUE SHIELD MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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