1902878408 NPI number — TRACIE FARRELL DODIG MD

Table of content: TRACIE FARRELL DODIG MD (NPI 1902878408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902878408 NPI number — TRACIE FARRELL DODIG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DODIG
Provider First Name:
TRACIE
Provider Middle Name:
FARRELL
Provider Name Prefix Text:
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:
FARRELL
Provider Other First Name:
TRACIE
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902878408
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14001 RIDGEDALE DR
Provider Second Line Business Mailing Address:
#100
Provider Business Mailing Address City Name:
MINNETONKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55305-1781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-473-0211
Provider Business Mailing Address Fax Number:
952-473-7908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14001 RIDGEDALE DR
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305-1781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-473-0211
Provider Business Practice Location Address Fax Number:
952-473-7908
Provider Enumeration Date:
02/07/2006

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: 208000000X , with the licence number:  43498 , 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: 087214800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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