1265429542 NPI number — GERARD L BOBELDYK MD

Table of content: GERARD L BOBELDYK MD (NPI 1265429542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265429542 NPI number — GERARD L BOBELDYK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOBELDYK
Provider First Name:
GERARD
Provider Middle Name:
L
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:
1265429542
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16472 LAUREL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST JOSEPH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-252-5131
Provider Business Mailing Address Fax Number:
320-240-2118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16472 LAUREL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST JOSEPH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-252-5131
Provider Business Practice Location Address Fax Number:
320-240-2118
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: 207R00000X , with the licence number:  26110 , 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: 6D057BO . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110104504 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 986003 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP22731 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 600903 . This is a "ARAZ GROUP/AMERICAS PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2114072 . This is a "FIRST HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0400499 . This is a "MEDICA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110893 . This is a "U-CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 037802000 . This is a "MEDICAL ASSISTANCE (MA)" identifier . This identifiers is of the category "OTHER".




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