1578643730 NPI number — MS. KRISTIN SKOOG KILDAHL MA LP

Table of content: MS. KRISTIN SKOOG KILDAHL MA LP (NPI 1578643730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578643730 NPI number — MS. KRISTIN SKOOG KILDAHL MA LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILDAHL
Provider First Name:
KRISTIN
Provider Middle Name:
SKOOG
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA LP
Provider Gender Code:
F

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:
1578643730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9923 BROOKSIDE CIRCLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55431-2826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-272-5107
Provider Business Mailing Address Fax Number:
952-657-5153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9001 E. BLOOMINGTON FREEWAY
Provider Second Line Business Practice Location Address:
STE 139D
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-657-5153
Provider Business Practice Location Address Fax Number:
952-657-5156
Provider Enumeration Date:
10/16/2006

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: 103T00000X , with the licence number:  LP1384 , 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: HP19178 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: BHP . This is a "BHP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 228G8K1 . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6295175 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 051250800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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