1386758373 NPI number — GILLETTE CHILDREN'S SPECIALTY HEALTHCARE

Table of content: MS. CATHERINE MARIE FEDDER ATC, MA, LATC (NPI 1528033131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386758373 NPI number — GILLETTE CHILDREN'S SPECIALTY HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1386758373
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 UNIVERSITY AVE E # 010614
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55101-2507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-325-2209
Provider Business Mailing Address Fax Number:
651-325-2221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 UNIVERSITY AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55101-2507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-726-2890
Provider Business Practice Location Address Fax Number:
651-726-2848
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARTZLER
Authorized Official First Name:
VANESSA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER PAYER RELATIONS AND STRATEG
Authorized Official Telephone Number:
651-325-2209

Provider Taxonomy Codes

  • Taxonomy code: 3336I0012X , with the licence number:  262713 , 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: 10025653700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1386758373 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8535290 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2049091 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 376978000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100440690B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1678053F , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21513 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33295600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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