Basic Information
| Provider Information | |||||||||
| NPI: | 1013908961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENNIS | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 JEFFERSON ST NORTH | ||||||||
| Address2: | |||||||||
| City: | WADENA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564821296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186313510 | ||||||||
| FaxNumber: | 2186317507 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 JEFFERSON ST NORTH | ||||||||
| Address2: | |||||||||
| City: | WADENA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564821296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186313510 | ||||||||
| FaxNumber: | 2186317507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 29545 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0702775 | 01 | MEDICA HEALTH PLANS | OTHER | 254013 | 01 | PREFERRED ONE | OTHER | 2114073 | 01 | FIRST HEALTH PLAN | OTHER | 50A46DE | 01 | BLUE CROSS BLUE SHIELD | OTHER | 110425 | 01 | U CARE | OTHER | HP25416 | 01 | HEALTH PARTNERS | OTHER | COMP | 01 | ONE HEALTH PLAN GREAT WES | OTHER | 160037460 | 01 | RR MEDICARE | OTHER | 338577900 | 05 | MN | MEDICAID | COMP | 01 | CHAMPUS | OTHER | 596760 | 01 | ARAZ GROUP AMERICAS PPO | OTHER |