1720274467 NPI number — NORTH MEMORIAL ENDOSCOPY CENTER AT MAPLE GROVE, LLC

Table of content: (NPI 1720274467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720274467 NPI number — NORTH MEMORIAL ENDOSCOPY CENTER AT MAPLE GROVE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH MEMORIAL ENDOSCOPY CENTER AT MAPLE GROVE, LLC
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:
1720274467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9855 HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 275
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55369-4778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9855 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 275
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55369-4778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-981-3200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MEVISSEN
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
763-981-3200

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1053443 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 227634 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 68-00093 . This is a "SELECTCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 68-00093 . This is a "PATIENT CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 48004500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5T42MA . This is a "BSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 68-00093 . This is a "LABORCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1720274467 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 68-00093 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".




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