1063457943 NPI number — ELK RIVER EYE CLINIC, P.A.

Table of content: (NPI 1063457943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063457943 NPI number — ELK RIVER EYE CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELK RIVER EYE CLINIC, P.A.
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:
1063457943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19022 FREEPORT AVE NW
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
ELK RIVER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55330-4767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-441-1055
Provider Business Mailing Address Fax Number:
763-441-7024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19022 FREEPORT AVE NW
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
ELK RIVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55330-4767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-441-1055
Provider Business Practice Location Address Fax Number:
763-441-7024
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOFFARD
Authorized Official First Name:
GARY
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
763-441-1055

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 98-22038 . This is a "MEDICA CLINIC NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 115815 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 52390HO . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 379314100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81961 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 96458 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5C159EL . This is a "BCBS MATERIALS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: CJ6982 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 21-15856 . This is a "MEDICA OPTICAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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