1801933627 NPI number — WILLIAM CLIFFORD BROSE O.D.,

Table of content: WILLIAM CLIFFORD BROSE O.D., (NPI 1801933627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801933627 NPI number — WILLIAM CLIFFORD BROSE O.D.,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROSE
Provider First Name:
WILLIAM
Provider Middle Name:
CLIFFORD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.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:
1801933627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6632 FLAG AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55428-1853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-535-7011
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12131 ELM CREEK BLVD N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55369-7093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-416-1983
Provider Business Practice Location Address Fax Number:
763-416-4084
Provider Enumeration Date:
01/31/2007

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: 152W00000X , with the licence number:  MN1544 , 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: 1808007 . This is a "DEFINITY HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2202190 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 168L0BR . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: BR952237 . This is a "HIGHMARK BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 219101033314 . This is a "PREFERED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 121823900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP39712 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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