1619905924 NPI number — DR. JEFFREY REX BRACE M.D.

Table of content: ELIZABETH DHARMAPAL (NPI 1104434257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619905924 NPI number — DR. JEFFREY REX BRACE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRACE
Provider First Name:
JEFFREY
Provider Middle Name:
REX
Provider Name Prefix Text:
DR.
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:
1619905924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2355 HIGHWAY 36 W STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55113-3905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-292-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2355 HIGHWAY 36 W STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55113-3905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-292-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2006

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: 2085N0700X , with the licence number:  44515 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 44515 , 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: 1034029 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 588T5BR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0091681 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16-02032 . This is a "MEDICA PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1811611 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 330412400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00253879 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0589325 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16-03496 . This is a "MEDICA CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: B592 . This is a "CHAMPUS/TRIWEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP44290 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 17131 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 34612300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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