1720111263 NPI number — MR. CHRISTOPHER PETER BERCHEM PT

Table of content: MR. CHRISTOPHER PETER BERCHEM PT (NPI 1720111263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720111263 NPI number — MR. CHRISTOPHER PETER BERCHEM PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERCHEM
Provider First Name:
CHRISTOPHER
Provider Middle Name:
PETER
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:
1720111263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8811 92ND ST S STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COTTAGE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55016-4037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-241-3777
Provider Business Mailing Address Fax Number:
651-241-3778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8811 92ND ST S
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
COTTAGE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55016-4036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-458-9446
Provider Business Practice Location Address Fax Number:
651-458-0817
Provider Enumeration Date:
03/13/2007

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: 2251X0800X , with the licence number:  4286 , 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)





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