1033107230 NPI number — BRADLEY W NEUJAHR OD PA

Table of content: (NPI 1033107230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033107230 NPI number — BRADLEY W NEUJAHR OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADLEY W NEUJAHR OD PA
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:
1033107230
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 2ND ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOSSTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56542-1301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-435-1010
Provider Business Mailing Address Fax Number:
218-435-1715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 2ND ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOSSTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56542-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-435-1010
Provider Business Practice Location Address Fax Number:
218-435-1715
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NEUJAHR
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
CEO OWNER
Authorized Official Telephone Number:
218-435-1010

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1892 , 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: 116599 . This is a "MEDICARE - U CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 410004074 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 050601001 . This is a "METROPOLITAN HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 63309FO . This is a "BCBS BLUE PLUS MATERIALS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 116599 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 982601006692 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 63235NE . This is a "BCBS OF MN FACILITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 63585NE . This is a "BCBS OF MN INDIVIDUAL DR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 137823600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22 24063 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".




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