1922060169 NPI number — SUSAN GROSSE-MACEMON

Table of content: SUSAN GROSSE-MACEMON (NPI 1922060169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922060169 NPI number — SUSAN GROSSE-MACEMON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSSE-MACEMON
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
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:
1922060169
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
153 CESAR CHAVEZ ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
W. ST. PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55107-2226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-222-1816
Provider Business Mailing Address Fax Number:
651-222-2226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
153 CESAR CHAVEZ ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
W. ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55107-2226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-222-1816
Provider Business Practice Location Address Fax Number:
651-222-2226
Provider Enumeration Date:
04/04/2006

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: 363LF0000X , with the licence number:  1451 , 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: 153842000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 923911025971 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0102292 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 108562 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 53M29GR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP26519 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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