1629010228 NPI number — KIDNEY SPECIALISTS OF MINNESOTA, PA

Table of content: (NPI 1629010228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629010228 NPI number — KIDNEY SPECIALISTS OF MINNESOTA, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDNEY SPECIALISTS OF MINNESOTA, PA
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:
1629010228
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6200 SHINGLE CREEK PKWY
Provider Second Line Business Mailing Address:
SUITE 260
Provider Business Mailing Address City Name:
BROOKLYN CENTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55430-2128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-561-5349
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6200 SHINGLE CREEK PKWY
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
BROOKLYN CENTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55430-2128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-561-5349
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
763-544-0696

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , 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: 3100002 . This is a "MEDICA PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 7764930 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 879710200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2109926 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: CP7137 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 16530 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32722000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 361 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 12416KI . This is a "BCBSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 279363181 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: C01015 . This is a "WPS MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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