Basic Information
| Provider Information | |||||||||
| NPI: | 1093751323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIXBY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ROLLINS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8301 GOLDEN VALLEY ROAD, SUITE 300 | ||||||||
| Address2: | NORTH MEMORIAL HEALTH CARE - CLINIC SERVICES | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554274484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635810908 | ||||||||
| FaxNumber: | 9527672380 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 39TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554214379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127062900 | ||||||||
| FaxNumber: | 6127062901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 08/27/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 24754 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | OD081BI | 01 | MN | BCBS | OTHER | 1000070 | 01 | MN | PREFERRED ONE | OTHER | 01-22161 | 01 | MN | MEDICA CHOICE & PRIMARY | OTHER | 102681 | 01 | MN | UCARE | OTHER | 21797 | 01 | MN | ARAZ | OTHER | 524377700 | 05 | MN | MEDICAID | HP27055 | 01 | MN | HEALTHPARTNERS | OTHER |