1972729176 NPI number — HOLLY MARIE GROSS

Table of content: (NPI 1972729176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972729176 NPI number — HOLLY MARIE GROSS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLY MARIE GROSS
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:
1972729176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/01/2008
NPI Reactivation Date:
07/31/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 E 1ST AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55705-1386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-229-2300
Provider Business Mailing Address Fax Number:
218-229-2005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 E 1ST AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55705-1386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-229-2300
Provider Business Practice Location Address Fax Number:
218-229-2005
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
218-229-2300

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5727 , 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: 591R5GR . This is a "BCBSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DD5185 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 235786100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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