1487665527 NPI number — JOSEPH J SACCOMAN MD

Table of content: JOSEPH J SACCOMAN MD (NPI 1487665527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487665527 NPI number — JOSEPH J SACCOMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SACCOMAN
Provider First Name:
JOSEPH
Provider Middle Name:
J
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:
1487665527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 SLOAN PL
Provider Second Line Business Mailing Address:
SUITE 35
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55117-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-772-1572
Provider Business Mailing Address Fax Number:
651-772-1889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 CENTENNIAL DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NORTH ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109-3086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-777-7414
Provider Business Practice Location Address Fax Number:
651-748-5839
Provider Enumeration Date:
08/11/2006

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: 207Q00000X , with the licence number:  34670 , 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: 167895700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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