1245236397 NPI number — JAGDEEP KOHLI MD

Table of content: JAGDEEP KOHLI MD (NPI 1245236397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245236397 NPI number — JAGDEEP KOHLI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOHLI
Provider First Name:
JAGDEEP
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1245236397
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:
910 E 26TH ST
Provider Second Line Business Mailing Address:
STE 210
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55404-4552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-879-1000
Provider Business Mailing Address Fax Number:
612-879-9116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 OSBORNE RD NE
Provider Second Line Business Practice Location Address:
STE 365
Provider Business Practice Location Address City Name:
FRIDLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55432-2769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-879-1000
Provider Business Practice Location Address Fax Number:
612-879-9116
Provider Enumeration Date:
06/23/2005

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: 2084N0400X , with the licence number:  39570 , 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: 112873100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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