1053392027 NPI number — DOWNTOWN SKYWAY FOOT SPECIALISTS INC

Table of content: (NPI 1053392027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053392027 NPI number — DOWNTOWN SKYWAY FOOT SPECIALISTS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOWNTOWN SKYWAY FOOT SPECIALISTS 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:
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:
1053392027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 NICOLLET MALL
Provider Second Line Business Mailing Address:
SUITE 517 MEDICAL ARTS BLDG
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55402-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-332-7720
Provider Business Mailing Address Fax Number:
612-333-8981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 NICOLLET MALL
Provider Second Line Business Practice Location Address:
SUITE 517 MEDICAL ARTS BLDG
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55402-2606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-332-7720
Provider Business Practice Location Address Fax Number:
612-333-8981
Provider Enumeration Date:
11/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LOCKNER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
BOLIN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
612-332-7720

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  359 , 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: 102943 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 768181046629 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 062096300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 165613 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2728357 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 535942 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 10074LO . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DC5459 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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