1962409995 NPI number — NORTH STAR PODIATRIC LAB, INC.

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 1962409995 NPI number — NORTH STAR PODIATRIC LAB, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH STAR PODIATRIC LAB, INC.
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:
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:
1962409995
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13419 FENWAY BLVD N
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
HUGO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55038-7465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-426-9388
Provider Business Mailing Address Fax Number:
651-426-7450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13419 FENWAY BLVD N
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
HUGO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55038-7465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-426-9388
Provider Business Practice Location Address Fax Number:
651-426-7450
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
CERTIFIED PEDORTHIST
Authorized Official Telephone Number:
651-426-9388

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 908817200 , issued by the state of ( FM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26569NO . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 66 . This is a "HEALTH PARTNERS PROVIDER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 418173203 . This is a "METRO HEALTH PLAN PROV NU" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8214553 . This is a "MEDICA PROVIDER NUMBER" identifier , issued by the state of ( FM ) . This identifiers is of the category "OTHER".




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