1770110629 NPI number — MADELINE MICHELLE ANDERSON HID

Table of content: MADELINE MICHELLE ANDERSON HID (NPI 1770110629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770110629 NPI number — MADELINE MICHELLE ANDERSON HID

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
MADELINE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HID
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEETS
Provider Other First Name:
MADELINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770110629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2901 LAVENDER PKWY STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARIBAULT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55021-5087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-333-3932
Provider Business Mailing Address Fax Number:
507-332-3011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 LAVENDER PKWY STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARIBAULT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55021-5087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-333-3932
Provider Business Practice Location Address Fax Number:
507-332-3011
Provider Enumeration Date:
03/23/2020

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: 237700000X , with the licence number:  2854 , 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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