1538180864 NPI number — THADDEUS STANLEY WALCZAK M.D.

Table of content: THADDEUS STANLEY WALCZAK M.D. (NPI 1538180864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538180864 NPI number — THADDEUS STANLEY WALCZAK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALCZAK
Provider First Name:
THADDEUS
Provider Middle Name:
STANLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1538180864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5775 WAYZATA BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-1222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-525-4511
Provider Business Mailing Address Fax Number:
952-525-1560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5775 WAYZATA BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-1222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-525-4511
Provider Business Practice Location Address Fax Number:
952-525-1560
Provider Enumeration Date:
07/22/2006

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: 2084N0400X , with the licence number:  40359 , 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: 792831 . This is a "AMERICAS PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 31Q17WA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: A011 . This is a "TRIWEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 130018102 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 338516700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10088 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41-1677590 . This is a "1ST CHOICE OF THE MIDWEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP7170 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01014968 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 05-81578 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 41-1677590 . This is a "WEA TRUST INSURANCE" identifier . This identifiers is of the category "OTHER".




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