1144214107 NPI number — THRESIAMMA AUGUSTINE JOSEPH MD

Table of content: THRESIAMMA AUGUSTINE JOSEPH MD (NPI 1144214107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144214107 NPI number — THRESIAMMA AUGUSTINE JOSEPH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOSEPH
Provider First Name:
THRESIAMMA
Provider Middle Name:
AUGUSTINE
Provider Name Prefix Text:
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:
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:
1144214107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3585 LEXINGTON AVE N
Provider Second Line Business Mailing Address:
STE 350
Provider Business Mailing Address City Name:
SHOREVIEW
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55126-8064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-251-5280
Provider Business Mailing Address Fax Number:
651-251-5282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3585 LEXINGTON AVE N
Provider Second Line Business Practice Location Address:
STE 350
Provider Business Practice Location Address City Name:
SHOREVIEW
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55126-8064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-484-3942
Provider Business Practice Location Address Fax Number:
651-787-0519
Provider Enumeration Date:
09/07/2005

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: 2080A0000X , with the licence number:  32036 , 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: 1201379 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 299L3J0 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: CP9090199004 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1203070 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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