1609876051 NPI number — HAMM MEMORIAL PSYCHIATRIC CLINIC

Table of content: (NPI 1609876051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609876051 NPI number — HAMM MEMORIAL PSYCHIATRIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAMM MEMORIAL PSYCHIATRIC CLINIC
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:
1609876051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 SAINT PETER ST
Provider Second Line Business Mailing Address:
STE 429
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55102-1130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-224-0614
Provider Business Mailing Address Fax Number:
651-224-5754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 SAINT PETER ST
Provider Second Line Business Practice Location Address:
STE 429
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102-1130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-224-0614
Provider Business Practice Location Address Fax Number:
651-224-5754
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JAEHNE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
651-224-0614

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  800960-1-MHC , 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: 23328HA . This is a "BC/BS" identifier . This identifiers is of the category "OTHER".




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