1386951317 NPI number — MYHEALTH FOR TEENS & YOUNG ADULTS

Table of content: (NPI 1386951317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386951317 NPI number — MYHEALTH FOR TEENS & YOUNG ADULTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYHEALTH FOR TEENS & YOUNG ADULTS
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:
WEST SUBURBAN TEEN CLINIC
Provider Other Organization Name Type Code:
4
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:
1386951317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 EIGHTH AVE. S.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOPKINS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55343-7667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-474-3251
Provider Business Mailing Address Fax Number:
952-767-0815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 EIGHTH AVE. S.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOPKINS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55343-7667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-474-3251
Provider Business Practice Location Address Fax Number:
952-767-0815
Provider Enumeration Date:
09/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LICHTY
Authorized Official First Name:
MEGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF ADMIN. & OPS.
Authorized Official Telephone Number:
952-767-0928

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 984772 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 438964600 . This is a "MINNESOTA HEALTH CARE PROGRAM" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: OAF89WE . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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