1023191590 NPI number — ROBERT DAVID MADOFF MD

Table of content: NICHOLAS WAYNE FENNELL (NPI 1750273926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023191590 NPI number — ROBERT DAVID MADOFF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADOFF
Provider First Name:
ROBERT
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1023191590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 FULTON ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55455-4800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-672-7422
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 FULTON ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-672-7422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2006

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: 208C00000X , with the licence number:  25693 , 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: 564R3MA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 100426 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0013003 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 14-00074 . This is a "MEDICA CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 841062300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24924 . This is a "ARAZ" identifier . This identifiers is of the category "OTHER".
  • Identifier: 14-00004 . This is a "MEDICA PRIMARY" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP13891 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0075089 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0582528 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 31621700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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