1932423878 NPI number — BRIAN J GRETEMAN, DPM, PA

Table of content: (NPI 1932423878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932423878 NPI number — BRIAN J GRETEMAN, DPM, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN J GRETEMAN, DPM, PA
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:
1932423878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3883 COON RAPIDS BLVD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COON RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55433-2518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-422-0233
Provider Business Mailing Address Fax Number:
763-422-9640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3883 COON RAPIDS BLVD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-2518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-422-0233
Provider Business Practice Location Address Fax Number:
763-422-9640
Provider Enumeration Date:
03/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GRETEMAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
763-422-0233

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  435 , 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: 873725800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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