1134173644 NPI number — FAIRMONT ORTHOPEDICS & SPORTS MEDICINE, PA

Table of content: (NPI 1134173644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134173644 NPI number — FAIRMONT ORTHOPEDICS & SPORTS MEDICINE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRMONT ORTHOPEDICS & SPORTS MEDICINE, PA
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:
1134173644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
717 S STATE ST STE 900
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56031-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-238-4949
Provider Business Mailing Address Fax Number:
507-238-3365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
717 S STATE ST
Provider Second Line Business Practice Location Address:
SUITE 900
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56031-4469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-238-4949
Provider Business Practice Location Address Fax Number:
507-238-3377
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
REVENUE CYCLE MANAGER ADMIN AP
Authorized Official Telephone Number:
507-238-4949

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QV0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CB1729 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 29D51FA . This is a "BLUE CROSS BLUE SHIELD CHIROPRACTIC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 112399 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 27084 . This is a "SANFORD HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 590024700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 974311025203 . This is a "PREF ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 40645WE . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 09809248 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 396G2PR . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 138808700 . This is a "US DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 29394 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".




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