Basic Information
| Provider Information | |||||||||
| NPI: | 1144368531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6300 SHINGLE CREEK PKWY | ||||||||
| Address2: | STE 600 | ||||||||
| City: | BROOKLYN CENTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554302124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637826400 | ||||||||
| FaxNumber: | 7637829558 | ||||||||
| Practice Location | |||||||||
| Address1: | 5775 WAYZATA BLVD STE 255 | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554161275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1227387106 | ||||||||
| FaxNumber: | 6122738727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6128840802 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 701372800 | 05 | MN | MEDICAID |