1467538413 NPI number — DR. CHARLES F MOLDOW MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467538413 NPI number — DR. CHARLES F MOLDOW MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MOLDOW

Provider First Name:

CHARLES

Provider Middle Name:

F

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1467538413

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

04/18/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

720 WASHINGTON AVE SE

Provider Second Line Business Mailing Address:

UNIVERSITY OF MINNESOTA PHYSICIANS

Provider Business Mailing Address City Name:

MINNEAPOLIS

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

55414-2924

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

612-884-0999

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

516 DELAWARE STREET S.E. CLINIC 3A

Provider Second Line Business Practice Location Address:

UNIVERSITY OF MINNESOTA PHYSICIANS

Provider Business Practice Location Address City Name:

MINNEAPOLIS

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

55455

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

612-884-0999

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

10/31/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RH0000X , with the licence number:  21787 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 05G93MO . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
• Identifier: 1017749 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
• Identifier: 122987 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 10387 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
• Identifier: 30-07017 . This is a "MEDICA CHOICE" identifier . This identifiers is of the category "OTHER".
• Identifier: 0051714 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
• Identifier: 0505529 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 30-00009 . This is a "MEDICA PRIMARY" identifier . This identifiers is of the category "OTHER".
• Identifier: HP28832 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
• Identifier: 30211800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 778277 . This is a "ARAZ" identifier . This identifiers is of the category "OTHER".
• Identifier: 7777470 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
• Identifier: 900321500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".