1790783587 NPI number — ORTONVILLE AREA HEALTH SERVICES

Table of content: (NPI 1790783587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790783587 NPI number — ORTONVILLE AREA HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTONVILLE AREA HEALTH SERVICES
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:
1790783587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 EASTVOLD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORTONVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56278-1252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-839-2502
Provider Business Mailing Address Fax Number:
320-839-4105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 EASTVOLD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORTONVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56278-1252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-839-2502
Provider Business Practice Location Address Fax Number:
320-839-4105
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROGERS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
320-839-2502

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  350419 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 984545300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3175 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5025407 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 512431 . This is a "AMERICA'S PPO/ARAZ PROVID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 117121841 . This is a "PRIMEWEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01014272 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6340680 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 300696 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5520390 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0120390 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1790HOR . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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