Basic Information
| Provider Information | |||||||||
| NPI: | 1033238308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINNESOTA NEUROLOGIC EVALUATIONS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27015 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681270015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023939459 | ||||||||
| FaxNumber: | 4023979895 | ||||||||
| Practice Location | |||||||||
| Address1: | 5355 320TH ST | ||||||||
| Address2: | |||||||||
| City: | CUSHING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564432128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185752097 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 10/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | DINVILLE | ||||||||
| AuthorizedOfficialFirstName: | JYL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN REIMBURSEMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4023975462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CCS-P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 15205 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 663270000 | 05 | MN | MEDICAID | 27T35MI | 01 | MN | BCBS GROUP # | OTHER | 27T36GA | 01 | MN | BCBS PIN | OTHER |