1548230196 NPI number — PHYLLIS C WIENER WHCNP

Table of content: PHYLLIS C WIENER WHCNP (NPI 1548230196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548230196 NPI number — PHYLLIS C WIENER WHCNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIENER
Provider First Name:
PHYLLIS
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
WHCNP
Provider Gender Code:
F

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:
1548230196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4028 ELLIOT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55407-3147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-822-1548
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 LAGOON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55408-2077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-823-6300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2006

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: 363LW0102X , with the licence number:  R1017050 , 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: 1075705 . This is a "AMERICA'S PPO (ARAZ)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 07-14658 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5K166WI . This is a "BCBS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1017710 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 142730 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 28721 . This is a "SIOUX VALLEY HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP17896 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".




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