1023001815 NPI number — ILBNC, P.A.

Table of content: (NPI 1023001815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023001815 NPI number — ILBNC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILBNC, P.A.
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:
6
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:
1023001815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 METRO DR
Provider Second Line Business Mailing Address:
SUITE 330
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-4506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-814-6600
Provider Business Mailing Address Fax Number:
952-814-6700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 METRO DR
Provider Second Line Business Practice Location Address:
SUITE 330
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55425-4506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-814-6600
Provider Business Practice Location Address Fax Number:
952-814-6700
Provider Enumeration Date:
08/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HILGARDNER
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CLINIC OPERATIONS MANAGER
Authorized Official Telephone Number:
952-814-6600

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , 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: 39370BA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 970722100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 76900 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com