1700831690 NPI number — KARLA GAY MYHRA-BLOOM M.D.

Table of content: KARLA GAY MYHRA-BLOOM M.D. (NPI 1700831690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700831690 NPI number — KARLA GAY MYHRA-BLOOM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYHRA-BLOOM
Provider First Name:
KARLA
Provider Middle Name:
GAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1700831690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 17TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARTELL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56377-1631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-259-0120
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 17TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-259-0120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2006

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: 2085R0202X , with the licence number:  35072 , 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: 1600536 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1016709 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 300099552 . This is a "RAILROAD MEDICARE WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 127385 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 300124849 . This is a "RAILROAD MEDICARE MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 56G37BL . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 706860300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 96D61MY . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 32423300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP33809 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1421754 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 253804 . This is a "MIDLANDS CHOICE INC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9238143 . This is a "DAKOTA CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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