1366456014 NPI number — MR. RICKY FRANCIS GROETSCH OD

Table of content: JOAN T. COOPER (NPI 1033158753)

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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