1821051327 NPI number — SHELLY L EDWARDS MA LP

Table of content: SHELLY L EDWARDS MA LP (NPI 1821051327)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821051327 NPI number — SHELLY L EDWARDS MA LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
SHELLY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA LP
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:
1821051327
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14115 JAMES RD STE 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROGERS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55374-9417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-575-8086
Provider Business Mailing Address Fax Number:
320-774-0415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14115 JAMES RD STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55374-9417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-575-8086
Provider Business Practice Location Address Fax Number:
320-774-0415
Provider Enumeration Date:
04/07/2006

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: 103T00000X , with the licence number:  LP3435 , 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: 6252137 . This is a "UBH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1023461 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 120585 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 63325900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11Q62ED . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP23171 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".




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