1649204645 NPI number — JUDY LYNN FRUEHBRODT-GLENZINSKI M.D.

Table of content: JUDY LYNN FRUEHBRODT-GLENZINSKI M.D. (NPI 1649204645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649204645 NPI number — JUDY LYNN FRUEHBRODT-GLENZINSKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRUEHBRODT-GLENZINSKI
Provider First Name:
JUDY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRUEHBRODT
Provider Other First Name:
JUDY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649204645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 STATE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARIBAULT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55021-6319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-333-3300
Provider Business Mailing Address Fax Number:
507-333-3214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 STATE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARIBAULT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-333-3300
Provider Business Practice Location Address Fax Number:
507-333-3214
Provider Enumeration Date:
07/10/2006

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: 207Q00000X , with the licence number:  41619 , 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: 603219200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080136009 . This is a "RAIL ROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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