Basic Information
| Provider Information | |||||||||
| NPI: | 1093131419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERIATRIC SERVICES OF MINNESOTA, LLC | ||||||||
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| OtherOrganizationName: | GENEVIVE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3433 BROADWAY ST NE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554131761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877737 | ||||||||
| FaxNumber: | 7635877781 | ||||||||
| Practice Location | |||||||||
| Address1: | 3433 BROADWAY ST NE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554131761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877737 | ||||||||
| FaxNumber: | 7635877781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2014 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | TUFANO | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | SIMPSON | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7635877737 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MHA, CMPE, CPPM | ||||||||
| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.