1982679700 NPI number — MARACON HEALTH CARE SERVICES, INC

Table of content: (NPI 1982679700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982679700 NPI number — MARACON HEALTH CARE SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARACON HEALTH CARE SERVICES, 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:
1982679700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1595 SELBY AVENUE, SUITE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104-6285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-641-0895
Provider Business Mailing Address Fax Number:
651-641-0894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1595 SELBY AVENUE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-6285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-641-0895
Provider Business Practice Location Address Fax Number:
651-641-0894
Provider Enumeration Date:
02/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NWACHUKU
Authorized Official First Name:
ONYEDIMMA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OF OPERATIONS
Authorized Official Telephone Number:
651-641-0895

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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: 70G05MA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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