1093184244 NPI number — BETHEL AVERBECK MD A PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1093184244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093184244 NPI number — BETHEL AVERBECK MD A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHEL AVERBECK MD A PROFESSIONAL MEDICAL CORPORATION
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:
6
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:
1093184244
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8170 33RD AVE S
Provider Second Line Business Mailing Address:
MAILSTOP 21110R
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-883-7469
Provider Business Mailing Address Fax Number:
952-883-5395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 CAPITOL MALL
Provider Second Line Business Practice Location Address:
22ND FLOOR
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95814-4407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-440-1001
Provider Business Practice Location Address Fax Number:
651-265-1800
Provider Enumeration Date:
09/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PALLATAO
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
952-883-5348

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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