1902875826 NPI number — ANNETTE W KUCK NP

Table of content: ANNETTE W KUCK NP (NPI 1902875826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902875826 NPI number — ANNETTE W KUCK NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUCK
Provider First Name:
ANNETTE
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1902875826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6025 LAKE RD
Provider Second Line Business Mailing Address:
STE110
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-1709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-735-7414
Provider Business Mailing Address Fax Number:
651-735-1827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6025 LAKE RD
Provider Second Line Business Practice Location Address:
STE110
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-1709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-735-7414
Provider Business Practice Location Address Fax Number:
651-735-1827
Provider Enumeration Date:
03/14/2006

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: 363LG0600X , with the licence number:  R089470-8 , 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: 34860000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP23673 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1008767 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 831022000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0407370 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 132742 . This is a "UCARE MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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