1154766525 NPI number — DR. BASSIM SAMADANI BIRKLAND M.D, M.P.H

Table of content: DR. BASSIM SAMADANI BIRKLAND M.D, M.P.H (NPI 1154766525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154766525 NPI number — DR. BASSIM SAMADANI BIRKLAND M.D, M.P.H

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIRKLAND
Provider First Name:
BASSIM
Provider Middle Name:
SAMADANI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D, M.P.H
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:
1154766525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1020 W BROADWAY AVE
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:
55411-2504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BROADWAY CLINIC
Provider Second Line Business Practice Location Address:
1020 WEST BROADWAY
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-302-8200
Provider Business Practice Location Address Fax Number:
612-521-4725
Provider Enumeration Date:
04/30/2013

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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