1588661276 NPI number — EQUITY SERVICES OF ST. PAUL, INC.

Table of content: (NPI 1588661276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588661276 NPI number — EQUITY SERVICES OF ST. PAUL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EQUITY SERVICES OF ST. PAUL, INC.
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:
1588661276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1169 RICE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55117-4901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-489-4656
Provider Business Mailing Address Fax Number:
651-489-4811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1169 RICE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55117-4901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-489-4656
Provider Business Practice Location Address Fax Number:
651-489-4811
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LARSON
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT AND C. E. O.
Authorized Official Telephone Number:
651-489-4656

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  326508 , 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: 064055700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2120EQ . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 102018 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5900024 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 24822 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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