1306904818 NPI number — MS. JANIS D. ANDERSON MA

Table of content: MS. JANIS D. ANDERSON MA (NPI 1306904818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306904818 NPI number — MS. JANIS D. ANDERSON MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
JANIS
Provider Middle Name:
D.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOGLUND
Provider Other First Name:
JANIS
Provider Other Middle Name:
D.A.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306904818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
645 2ND ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PERHAM
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56573-1101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-346-5384
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 CHARLES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAINERD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56401-3208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-855-1247
Provider Business Practice Location Address Fax Number:
218-855-1248
Provider Enumeration Date:
12/05/2006

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: 231H00000X , with the licence number:  5118 , 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: 12D08HE . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 411945552 . This is a "FEDERAL ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4500073 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 12D08HE . This is a "BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 7314680-00 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18DO8HE . This is a "BCBS DME" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4308814 . This is a "STATE ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 640003703 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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