1033453303 NPI number — MRS. JENNIFER E BRUYERE BA, AAS, RT(R)(M)

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033453303 NPI number — MRS. JENNIFER E BRUYERE BA, AAS, RT(R)(M)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUYERE
Provider First Name:
JENNIFER
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BA, AAS, RT(R)(M)
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDWARDS
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
BA, AAS, RT(R)(M)
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033453303
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4235 32ND AVE S
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:
55406-3315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-729-2205
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4235 32ND AVE S
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:
55406-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-729-2205
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/26/2012

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: 247100000X , with the licence number:  373912 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2471M2300X , with the licence number: 373912 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500506806 . This is a "IEMA DIVISION OF NUCLEAR SAFETY" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 373912 . This is a "AMERICAN REGISTRY OF RADIOLOGIC TECHNOLOGISTS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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