1104370683 NPI number — TAIT ANDERSON

Table of content: TAIT ANDERSON (NPI 1104370683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104370683 NPI number — TAIT ANDERSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
TAIT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1104370683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1772 STEIGER LAKE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTORIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55386-7723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-443-9888
Provider Business Mailing Address Fax Number:
952-443-9804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8758 EGAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVAGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55378-2561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-443-9888
Provider Business Practice Location Address Fax Number:
952-443-9804
Provider Enumeration Date:
08/12/2016

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: 235Z00000X , with the licence number:  9497 , 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: 001442700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16154051 . This is a "PT CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 565581028804 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 017J6KI . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1311578 . This is a "ARAZ/AMERICA'S PPO/CIGNA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 169036 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 76842 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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