1902851876 NPI number — DR. TAMARA PIROSKA PETRAC-HALATSIS MD

Table of content: DR. TAMARA PIROSKA PETRAC-HALATSIS MD (NPI 1902851876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902851876 NPI number — DR. TAMARA PIROSKA PETRAC-HALATSIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRAC-HALATSIS
Provider First Name:
TAMARA
Provider Middle Name:
PIROSKA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETRAC
Provider Other First Name:
TAMARA
Provider Other Middle Name:
PIROSKA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1902851876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5200 FAIRVIEW BOULEVARD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYOMING
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-982-7670
Provider Business Mailing Address Fax Number:
651-982-7675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5200 FAIRVIEW BOULEVARD
Provider Second Line Business Practice Location Address:
OB/GYN DEPARTMENT
Provider Business Practice Location Address City Name:
WYOMING
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-982-7670
Provider Business Practice Location Address Fax Number:
651-982-7675
Provider Enumeration Date:
05/22/2006

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: 207V00000X , with the licence number:  ME94155 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 53965 , 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: 274695600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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