1093898322 NPI number — NW FAMILY PRACTICE ROGERS

Table of content: (NPI 1093898322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093898322 NPI number — NW FAMILY PRACTICE ROGERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NW FAMILY PRACTICE ROGERS
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:
1093898322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21305 JOHN MILLESS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROGERS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55374-9450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21305 JOHN MILLESS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55374-9450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-428-2206
Provider Business Practice Location Address Fax Number:
612-428-2530
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHACKELFORD
Authorized Official First Name:
DIRENDIA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGED CARE SPECIALIST
Authorized Official Telephone Number:
800-654-0889

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  17330 , 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: 2423616 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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