1902134877 NPI number — CENTRAL MINNESOTA RETINA CONSULTANTS, PLLC

Table of content: (NPI 1902134877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902134877 NPI number — CENTRAL MINNESOTA RETINA CONSULTANTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL MINNESOTA RETINA CONSULTANTS, PLLC
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:
6
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:
1902134877
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2330 TROOP DR
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
SARTELL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56377-4530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-230-8555
Provider Business Mailing Address Fax Number:
320-230-8556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2330 TROOP DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-4530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-230-8555
Provider Business Practice Location Address Fax Number:
320-230-8556
Provider Enumeration Date:
12/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
REYNOLDS
Authorized Official First Name:
DALE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
320-230-8555

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  45473 , 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: 569S2CE . This is a "BLUECROSS BLUESHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 807932300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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