1336102763 NPI number — MARK JAMES ZIEBARTH PMHCNS-BC

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 1336102763 NPI number — MARK JAMES ZIEBARTH PMHCNS-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZIEBARTH
Provider First Name:
MARK
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHCNS-BC
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:
1336102763
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 SILVER LAKE RD NW
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112-1786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-628-9566
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 SILVER LAKE RD NW
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
NEW BRIGHTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55112-1786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-628-9566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2006

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: 103T00000X , with the licence number:  LP2295 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: R0820659 , 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: 1011796 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP25418 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 641K1ZI . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 816750801 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8363352 . This is a "UBH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 990991011796 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 208M0Z1 . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6267250 . This is a "UBH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 890001087 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 167750 . This is a "BHP UCARE" identifier . This identifiers is of the category "OTHER".




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