1992780712 NPI number — DR. LESLIE GLEN MASSOGLIA MD

Table of content: DR. NICHOLAS MELVIN RUNEARE MD (NPI 1508390642)

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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