1891762688 NPI number — WILLIAM J MULLIN MD

Table of content: WILLIAM J MULLIN MD (NPI 1891762688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891762688 NPI number — WILLIAM J MULLIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLIN
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1891762688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1450
Provider Second Line Business Mailing Address:
NW 6035
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55485-6035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-542-8553
Provider Business Mailing Address Fax Number:
952-513-6880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5775 WAYZATA BLVD
Provider Second Line Business Practice Location Address:
STE 190
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-541-1840
Provider Business Practice Location Address Fax Number:
952-513-6880
Provider Enumeration Date:
03/01/2006

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: 2085R0202X , with the licence number:  36643 , 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: 091527100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105162500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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