1124087622 NPI number — DR. ELISE CHRISTINE BRODIN LARSON MD

Table of content: DR. ELISE CHRISTINE BRODIN LARSON MD (NPI 1124087622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124087622 NPI number — DR. ELISE CHRISTINE BRODIN LARSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
ELISE
Provider Middle Name:
CHRISTINE BRODIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRODIN
Provider Other First Name:
ELISE
Provider Other Middle Name:
CHRISTINE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124087622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
323 WASHINGTON AVE N STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55401-2206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-698-9860
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5130 MAIN ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRIDLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55421-1528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-216-1471
Provider Business Practice Location Address Fax Number:
833-972-1587
Provider Enumeration Date:
03/22/2006

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: 207Q00000X , with the licence number:  40650 , 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)





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