1043236896 NPI number — MINNESOTA SPINE REHAB, INC

Table of content: (NPI 1043236896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043236896 NPI number — MINNESOTA SPINE REHAB, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA SPINE REHAB, INC
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:
SPECIALISTS IN OCCUPATIONAL & ENVRIONMENTAL MEDICINE
Provider Other Organization Name Type Code:
5
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:
1043236896
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 SHERMAN ST
Provider Second Line Business Mailing Address:
SUITE 470
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55102-2564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-209-6520
Provider Business Mailing Address Fax Number:
651-209-6521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 SHERMAN ST
Provider Second Line Business Practice Location Address:
SUITE 470
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102-2564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-209-6520
Provider Business Practice Location Address Fax Number:
651-209-6521
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIKHAIL
Authorized Official First Name:
SHERIEF
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
651-209-6520

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X , with the licence number:  33701 , 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: 47D55MI . This is a "BCBS OF MN CLINIC NUMBER" identifier , issued by the state of ( FM ) . This identifiers is of the category "OTHER".
  • Identifier: 79737 . This is a "HEALTH PARTNERS GROUP NUM" identifier , issued by the state of ( FM ) . This identifiers is of the category "OTHER".
  • Identifier: 9800099 . This is a "MEDICA GROUP NUMBER" identifier , issued by the state of ( FM ) . This identifiers is of the category "OTHER".
  • Identifier: A001 . This is a "TRICARE GROUP NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 306C . This is a "CHOICE PLUS GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: F703 . This is a "UCARE GROUP NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 509491027972 . This is a "PREFERRED ONE GROUP NUMBE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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