1871630533 NPI number — DR. MISCHEL B. WALGREN PHD

Table of content: DR. MISCHEL B. WALGREN PHD (NPI 1871630533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871630533 NPI number — DR. MISCHEL B. WALGREN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALGREN
Provider First Name:
MISCHEL
Provider Middle Name:
B.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

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:
1871630533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 OAK GROVE STREET, LORING PARK OFFICE BUILDING
Provider Second Line Business Mailing Address:
#407
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55403-3234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-874-8937
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3805 KIPLING AVE
Provider Second Line Business Practice Location Address:
MINNEAPOLIS, MN
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-4945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-267-6062
Provider Business Practice Location Address Fax Number:
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: 101YM0800X , with the licence number:  LP1579 , 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: 30814WA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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