Basic Information
| Provider Information | |||||||||
| NPI: | 1053952606 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW EXPRESS CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | M HEALTH FAIRVIEW RECOVERY CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 UNIVERSITY AVE W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551043727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726740 | ||||||||
| FaxNumber: | 6126726041 | ||||||||
| Practice Location | |||||||||
| Address1: | 2312 S 6TH ST STE F105 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122733565 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2019 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6126726594 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.