1912066952 NPI number — JOHN BERNARD MISCHKE MA LP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912066952 NPI number — JOHN BERNARD MISCHKE MA LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISCHKE
Provider First Name:
JOHN
Provider Middle Name:
BERNARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA LP
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:
1912066952
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:
480 WHEELOCK PKWY W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55117-4258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-489-0149
Provider Business Mailing Address Fax Number:
651-654-7065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
821 RAYMOND AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-647-0659
Provider Business Practice Location Address Fax Number:
651-647-0659
Provider Enumeration Date:
12/06/2006

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: 103T00000X , with the licence number:  2396 , 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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