1205823440 NPI number — WALTER PAUL GLEICH M.D.

Table of content: WALTER PAUL GLEICH M.D. (NPI 1205823440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205823440 NPI number — WALTER PAUL GLEICH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLEICH
Provider First Name:
WALTER
Provider Middle Name:
PAUL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1205823440
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 UNIVERSITY AVE W
Provider Second Line Business Mailing Address:
SUITE 240N
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-1052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-999-6909
Provider Business Mailing Address Fax Number:
651-297-6115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 SHERMAN ST
Provider Second Line Business Practice Location Address:
SUITE 450
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102-2564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-999-6800
Provider Business Practice Location Address Fax Number:
651-999-6808
Provider Enumeration Date:
10/03/2005

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: 208800000X , with the licence number:  26841 , 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: 390208100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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