1669419610 NPI number — MR. KELLY J SOUKUP PT

Table of content: MR. KELLY J SOUKUP PT (NPI 1669419610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669419610 NPI number — MR. KELLY J SOUKUP PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUKUP
Provider First Name:
KELLY
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1669419610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19052 INMAN TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55044-4701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-469-6925
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 W 140TH ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
BURNSVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55337-4480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-808-3052
Provider Business Practice Location Address Fax Number:
952-846-2202
Provider Enumeration Date:
05/31/2006

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: 225100000X , with the licence number:  7269 , 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: 210K0SO . This is a "BLUECROSS BLUESHEILD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 011698000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6404216 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP39430 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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