1992780712 NPI number — DR. LESLIE GLEN MASSOGLIA MD

Table of content: MARIA O'FARRELL OTR/L (NPI 1366961765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992780712 NPI number — DR. LESLIE GLEN MASSOGLIA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASSOGLIA
Provider First Name:
LESLIE
Provider Middle Name:
GLEN
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:
AHLERS
Provider Other First Name:
LESLIE
Provider Other Middle Name:
GLEN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992780712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4845 SAFARI CT N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55122-2617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-461-3813
Provider Business Mailing Address Fax Number:
651-305-0595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4845 SAFARI CT N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-461-3813
Provider Business Practice Location Address Fax Number:
952-431-5334
Provider Enumeration Date:
12/14/2005

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: 207Q00000X , with the licence number:  43602 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0401X , with the licence number: 43602 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: 43602 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QH0002X , with the licence number: 43602 , 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: 117R2BA, 015K3BA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 20153 . This is a "SVHP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0107062, 39-09161 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 117R2BA, 015K3BA . This is a "MNCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: NA9501028427 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 080172550 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 140964 . This is a "MNCARE-U" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 564110100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP33926 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 363606405 . This is a "CHAMPUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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