1497741185 NPI number — DR. CRAIG ALAN COUILLARD DC

Table of content: DR. STEVEN N CONNELLY M.D. (NPI 1689629677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497741185 NPI number — DR. CRAIG ALAN COUILLARD DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUILLARD
Provider First Name:
CRAIG
Provider Middle Name:
ALAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1497741185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9202 202ND ST W
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
LAKEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55044-6855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-469-8385
Provider Business Mailing Address Fax Number:
952-469-1713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9202 202ND ST W
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
LAKEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55044-7915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-469-8385
Provider Business Practice Location Address Fax Number:
952-469-1713
Provider Enumeration Date:
09/27/2005

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: 111NS0005X , with the licence number:  3955 , 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: 727678800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 350002308 . This is a "MEDICAR PTAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 411991603 . This is a "FEDERAL TAX ID #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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