1881739241 NPI number — MS. LAURA J TRIPET DODGE

Table of content: MS. LAURA J TRIPET DODGE (NPI 1881739241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881739241 NPI number — MS. LAURA J TRIPET DODGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DODGE
Provider First Name:
LAURA
Provider Middle Name:
J TRIPET
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
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:
1881739241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 EXCELSIOR BLVD
Provider Second Line Business Mailing Address:
SUITE 501A
Provider Business Mailing Address City Name:
ST LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-933-3121
Provider Business Mailing Address Fax Number:
952-933-3511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4601 EXCELSIOR BLVD
Provider Second Line Business Practice Location Address:
SUITE 501A
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-933-3121
Provider Business Practice Location Address Fax Number:
952-933-3511
Provider Enumeration Date:
02/21/2007

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: 103TC0700X , with the licence number:  LP1396 , 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: 079N9TR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 975348600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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