1023335866 NPI number — DR. BRIAN STUART GOULD M.D.

Table of content: DR. BRIAN STUART GOULD M.D. (NPI 1023335866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023335866 NPI number — DR. BRIAN STUART GOULD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOULD
Provider First Name:
BRIAN
Provider Middle Name:
STUART
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1023335866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7590 LYRIC LN NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRIDLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55432-3251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-236-3800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2925 CHICAGO AVE
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:
55407-1321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-262-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2010

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: 2084P0800X , with the licence number:  53569 , 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)