Basic Information
Provider Information | |||||||||
NPI: | 1154332401 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | URBAN | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6465 WAYZATA BLVD | ||||||||
Address2: | SUITE 900 | ||||||||
City: | ST LOUIS PARK | ||||||||
State: | MN | ||||||||
PostalCode: | 554261728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525125600 | ||||||||
FaxNumber: | 9525125650 | ||||||||
Practice Location | |||||||||
Address1: | 7373 FRANCE AVE S | ||||||||
Address2: | SUITE 312 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554354534 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528320076 | ||||||||
FaxNumber: | 9528320477 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2006 | ||||||||
LastUpdateDate: | 01/15/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 35237 | MN | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
ID | Type | State | Issuer | Description | 969990638008 | 01 |   | PREFERREDONE | OTHER | 55A81UR | 01 |   | BLUECROSS BLUESHIELD | OTHER | 235302400 | 05 | MN |   | MEDICAID | HP14598 | 01 |   | HEALTHPARTNERS | OTHER | 32025100 | 01 |   | WISC MEDICAID | OTHER | 108122C689 | 01 |   | UCARE | OTHER | 925053 | 01 |   | MEDICA | OTHER |