1982601647 NPI number — MR. MARK RANDY HALSTROM MD

Table of content: MR. MARK RANDY HALSTROM MD (NPI 1982601647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982601647 NPI number — MR. MARK RANDY HALSTROM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALSTROM
Provider First Name:
MARK
Provider Middle Name:
RANDY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1982601647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 296
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARTELL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56377-0296
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-251-2600
Provider Business Mailing Address Fax Number:
320-251-4763

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 2ND ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-1977
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-251-2600
Provider Business Practice Location Address Fax Number:
320-251-4763
Provider Enumeration Date:
07/07/2005

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: 207Q00000X , with the licence number:  42506 , 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: 339524300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 169318P539 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP30911 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 41D31HA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: MR143-104661 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01-05807 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 031216004 . This is a "PRIME WEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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