1366550923 NPI number — DR. JEFFREY L. RAINES

Table of content: DR. JEFFREY L. RAINES (NPI 1366550923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366550923 NPI number — DR. JEFFREY L. RAINES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAINES
Provider First Name:
JEFFREY
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1366550923
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6401 UNIVERSITY AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRIDLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55432-4341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-572-5710
Provider Business Mailing Address Fax Number:
763-571-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14500 99TH AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55369-4730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-898-1520
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2006

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: 207V00000X , with the licence number:  44383 , 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: 0702163 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1493817 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 7760362 . This is a "AETNA INS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 50G94RA . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1029424 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 141532 . This is a "UCARE MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 382151000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP34719 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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