1053357004 NPI number — JAMES H. ANDRISEVIC M.D.

Table of content: JAMES H. ANDRISEVIC M.D. (NPI 1053357004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053357004 NPI number — JAMES H. ANDRISEVIC M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDRISEVIC
Provider First Name:
JAMES
Provider Middle Name:
H.
Provider Name Prefix Text:
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:
1053357004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 E NICOLLET BLVD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
BURNSVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55337-4522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-435-4140
Provider Business Mailing Address Fax Number:
952-435-4189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4570 W 77TH ST
Provider Second Line Business Practice Location Address:
SUITE 235
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-5008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-832-0805
Provider Business Practice Location Address Fax Number:
952-832-5597
Provider Enumeration Date:
06/20/2006

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: 208600000X , with the licence number:  23231 , 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: 23231 . This is a "MN LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP12805 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1727004 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 25107 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 138J7AN . This is a "BLUECROSS/BLUE SHIELD MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 112126 . This is a "UCARE MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 961901000016 . This is a "PREFERREDONE" identifier , issued by the state of ( FM ) . This identifiers is of the category "OTHER".




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