1386758373 NPI number — GILLETTE CHILDREN'S SPECIALTY HEALTHCARE

Table of content: (NPI 1386758373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386758373 NPI number — GILLETTE CHILDREN'S SPECIALTY HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
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:
GILLETTE CHILDRENS SPECIALTY HEALTHCARE
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:
1386758373
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 UNIVERSITY AVE E # 010614
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:
55101-2507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-325-2209
Provider Business Mailing Address Fax Number:
651-325-2221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 UNIVERSITY AVE E
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:
55101-2507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-726-2890
Provider Business Practice Location Address Fax Number:
651-726-2848
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARTZLER
Authorized Official First Name:
VANESSA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER PAYER RELATIONS AND STRATEG
Authorized Official Telephone Number:
651-325-2209

Provider Taxonomy Codes

  • Taxonomy code: 3336I0012X , with the licence number:  262713 , 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: 10025653700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1386758373 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8535290 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2049091 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 376978000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100440690B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1678053F , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21513 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33295600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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