1356524540 NPI number — FAIRVIEW EXPRESS CARE

Table of content: (NPI 1356524540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356524540 NPI number — FAIRVIEW EXPRESS CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRVIEW EXPRESS CARE
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:
FAIRVIEW ANDOVER CLINIC (EYEWEAR)
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:
1356524540
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9372
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55440-9372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-672-6724
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13819 HANSON BLVD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDOVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55304-7608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-572-5700
Provider Business Practice Location Address Fax Number:
763-392-4052
Provider Enumeration Date:
12/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
VP REVENUE MANAGEMENT
Authorized Official Telephone Number:
612-672-6594

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 21-00115 . This is a "EYECRAFT LAB" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 126908 . This is a "UCARE EYEWARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 52Q42CO . This is a "BCBS EYEWARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 21181 . This is a "MEDICA EYEWARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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