Basic Information
| Provider Information | |||||||||
| NPI: | 1124210760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW CLINICS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAIRVIEW CLINICS-ROGERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9372 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554409372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726724 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14040 NORTHDALE BLVD | ||||||||
| Address2: | STE 10 | ||||||||
| City: | ROGERS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553749612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634884100 | ||||||||
| FaxNumber: | 7634884105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2007 | ||||||||
| LastUpdateDate: | 10/09/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FROMM | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6126724976 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 430067100 | 05 | MN | MEDICAID |