1366456014 NPI number — MR. RICKY FRANCIS GROETSCH OD

Table of content: MR. RICKY FRANCIS GROETSCH OD (NPI 1366456014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366456014 NPI number — MR. RICKY FRANCIS GROETSCH OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROETSCH
Provider First Name:
RICKY
Provider Middle Name:
FRANCIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1366456014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 E MAIN ST STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELROSE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56352-1485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-256-4000
Provider Business Mailing Address Fax Number:
320-256-4002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 E MAIN ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELROSE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56352-1485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-256-4000
Provider Business Practice Location Address Fax Number:
320-256-4002
Provider Enumeration Date:
07/28/2006

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: 152W00000X , with the licence number:  MN 2082 , 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: 0F373GR . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 115186 . This is a "UCARE PROVIDER NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2225597 . This is a "MEDICA PROVIDER NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 380225600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47576 . This is a "HEALTH PARTNERS PROVIDER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: MN2082 . This is a "EYEMED PROVIDER NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1006663 . This is a "PREFERRED ONE PROVIDER NU" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 410031767 . This is a "RAILROAD MEDICARE PROVIDE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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