1700208337 NPI number — TILLGES CERTIFIED ORTHOTIC PROSTHETIC, INC.

Table of content: (NPI 1700208337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700208337 NPI number — TILLGES CERTIFIED ORTHOTIC PROSTHETIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TILLGES CERTIFIED ORTHOTIC PROSTHETIC, INC.
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:
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:
1700208337
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1570 BEAM AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MAPLEWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55109-1166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-772-2665
Provider Business Mailing Address Fax Number:
651-771-6553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 PORTLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55404-1145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-341-3660
Provider Business Practice Location Address Fax Number:
612-341-3664
Provider Enumeration Date:
01/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
TILLGES
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
651-772-2665

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1018417 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 102162 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2G045TI . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 78026500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21446 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 41783200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8200377 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".




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