1386896744 NPI number — GERMANSON MD PSYCHIATRY LTD

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 1386896744 NPI number — GERMANSON MD PSYCHIATRY LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERMANSON MD PSYCHIATRY LTD
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:
1386896744
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1161 WAYZATA BLVD E
Provider Second Line Business Mailing Address:
#228
Provider Business Mailing Address City Name:
WAYZATA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55391-1935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-956-4057
Provider Business Mailing Address Fax Number:
952-333-8196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13911 RIDGEDALE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-956-4057
Provider Business Practice Location Address Fax Number:
952-333-8196
Provider Enumeration Date:
10/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GERMANSON
Authorized Official First Name:
TWILA
Authorized Official Middle Name:
BAUER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
952-956-4057

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  43294 , 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: 816898900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 279GIGE . This is a "BCBSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 171122 . This is a "VCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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