1609921899 NPI number — BIRCH LAKE VISION GROUP, LLC.

Table of content: (NPI 1609921899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609921899 NPI number — BIRCH LAKE VISION GROUP, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIRCH LAKE VISION GROUP, LLC.
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:
1609921899
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4720 WHITE BEAR PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE BEAR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110-3336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-426-2747
Provider Business Mailing Address Fax Number:
651-426-9838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4720 WHITE BEAR PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55110-3336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-426-2747
Provider Business Practice Location Address Fax Number:
651-426-9838
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRUDEM
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
DWIGHT
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
651-426-2747

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  LD1732000 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: LD2695000 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 22-01733 . This is a "MEDICA (BIRCH LAKE)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 244ROLU . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00116310 . This is a "MEDICARE RAILROAD RETIREM" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00124841 . This is a "MEDICARE RAILROAD RETIREM" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-02690 . This is a "MEDICA (BIRCH LAKE)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 965401019270 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-02779 . This is a "MEDICA (VILLAGE)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP29577 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: ON456GR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-02780 . This is a "MEDICA (VILLAGE CLINIC)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 965400656001 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP27080 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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