1902839947 NPI number — TWO RIVERS LUNG SPECIALISTS, P. A.

Table of content: (NPI 1902839947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902839947 NPI number — TWO RIVERS LUNG SPECIALISTS, P. A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWO RIVERS LUNG SPECIALISTS, P. A.
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:
1902839947
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4040 COON RAPIDS BLVD NW
Provider Second Line Business Mailing Address:
SUITE #100
Provider Business Mailing Address City Name:
COON RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55433-2522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-236-9494
Provider Business Mailing Address Fax Number:
763-236-9495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4040 COON RAPIDS BLVD NW
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-2522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-236-9494
Provider Business Practice Location Address Fax Number:
763-236-9495
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
JEANNE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
763-236-9494

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  1564 , 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: 83654 . This is a "HEALTH PART" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: CJ7024 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 142464 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0001 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 193J9TW . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 788700100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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