1912970708 NPI number — MR. PETER JOHN LINDBLOOM PA C

Table of content: MR. PETER JOHN LINDBLOOM PA C (NPI 1912970708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912970708 NPI number — MR. PETER JOHN LINDBLOOM PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LINDBLOOM
Provider First Name:
PETER
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA C
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:
1912970708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 ELM ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONAMIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56359-7901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-532-3154
Provider Business Mailing Address Fax Number:
320-532-3111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 ELM ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONAMIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56359-7901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-532-3154
Provider Business Practice Location Address Fax Number:
320-532-3111
Provider Enumeration Date:
02/10/2006

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: 363AM0700X , with the licence number:  9314 , 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: 01-19641 . This is a "MEDICA ISLE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP23883 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 551295600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01-13520 . This is a "MEDICA ONAMIA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: NA9091033077 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 410785161002 . This is a "TRICARE CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 562S8LI . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 142458 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 18358 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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