1538213566 NPI number — GROUP HEALTH PLAN, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538213566 NPI number — GROUP HEALTH PLAN, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROUP HEALTH PLAN, INC
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:
1538213566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8100 34TH AVE S
Provider Second Line Business Mailing Address:
21113A
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-1672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-883-5151
Provider Business Mailing Address Fax Number:
952-883-5160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2251 CONNECTICUT AVE
Provider Second Line Business Practice Location Address:
HEALTHPARTNERS CENTRAL MN CLINIC - DENTAL
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56337-4772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-253-5824
Provider Business Practice Location Address Fax Number:
320-203-2076
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GESKO
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DENTAL DIRECTOR AND SR. VICE PRESID
Authorized Official Telephone Number:
952-883-7577

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7477163-00 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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