1700846995 NPI number — DR. JOHN MICHAEL COLEMAN M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700846995 NPI number — DR. JOHN MICHAEL COLEMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLEMAN
Provider First Name:
JOHN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1700846995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4770 WHITE BEAR PARKWAY, LL
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:
55110-3394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-426-0698
Provider Business Mailing Address Fax Number:
651-426-6439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
347 NORTH SMITH AVE
Provider Second Line Business Practice Location Address:
SUITE 505
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102-3367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-220-6260
Provider Business Practice Location Address Fax Number:
651-220-7777
Provider Enumeration Date:
03/23/2006

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: 174400000X , with the licence number:  MN24195 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080N0001X , with the licence number: 24195 , 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: 357705800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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