1114919024 NPI number — BRIAN J GRETEMAN DPM, PA

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114919024 NPI number — BRIAN J GRETEMAN DPM, PA

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

GRETEMAN

Provider First Name:

BRIAN

Provider Middle Name:

J

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DPM, PA

Provider Gender Code:

M

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:

1114919024

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/07/2008

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3883 COON RAPIDS BLVD NW

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

COON RAPIDS

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

55433-2518

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

763-422-0233

Provider Business Mailing Address Fax Number:

763-422-9640

Provider First Line Business Practice Location Address:

3883 COON RAPIDS BLVD NW

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

COON RAPIDS

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

55433-2518

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

763-422-0233

Provider Business Practice Location Address Fax Number:

763-422-9640

Provider Enumeration Date:

08/17/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 213E00000X , with the licence number:  MN 435 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 480032360 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 1685548 . This is a "ARAZ" identifier . This identifiers is of the category "OTHER".
• Identifier: 23283 . This is a "GROUP HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 27-25644 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
• Identifier: 41-1984647 . This is a "TRI-CARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 109919 . This is a "CHOICE PLUS" identifier . This identifiers is of the category "OTHER".
• Identifier: 1B746GR . This is a "BC/BS (GROUP)" identifier . This identifiers is of the category "OTHER".
• Identifier: 107452 . This is a "U-CARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 9H364GR . This is a "BC/BS (PIN)" identifier . This identifiers is of the category "OTHER".
• Identifier: HP17598 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
• Identifier: 75928 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
• Identifier: 873725800 . This is a "MN MA" identifier . This identifiers is of the category "OTHER".
• Identifier: 873725800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 961510781001 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".