1255310298 NPI number — DR. TARA L BROADWATER MD

Table of content: DR. TARA L BROADWATER MD (NPI 1255310298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255310298 NPI number — DR. TARA L BROADWATER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROADWATER
Provider First Name:
TARA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
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:
1255310298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
898 WESCOTT TRL APT 311
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55123-2272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-304-1899
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
898 WESCOTT TRL APT 311
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55123-2272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-304-1899
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2006

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: 207Q00000X , with the licence number:  40655 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 40655 , 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: 388R8BU . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0573816 . This is a "MEDICAID" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: NA2951032151 . This is a "PREFFERED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP36174 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1965380 . This is a "AMERICAS PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 124673 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 41084933956001C212 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 526011600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00138242 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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