Basic Information
Provider Information | |||||||||
NPI: | 1164491908 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEBSKOWSKI | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8100 NORTHLAND DR | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554314800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528065619 | ||||||||
FaxNumber: | 9528065510 | ||||||||
Practice Location | |||||||||
Address1: | 8100 NORTHLAND DR | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554314800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528065619 | ||||||||
FaxNumber: | 9528065510 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2006 | ||||||||
LastUpdateDate: | 01/02/2013 | ||||||||
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 | 2251X0800X | 6090 | MN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
ID | Type | State | Issuer | Description | 059G6WE | 01 |   | BCBS | OTHER | 104667 | 01 |   | UCARE | OTHER | 6090 | 01 |   | MN STATE LICENSE | OTHER | 6576528 | 01 |   | AOA ST TAX | OTHER | 989211040352 | 01 |   | PREFERRED ONE | OTHER | HP40440 | 01 |   | HEALTH PARTNERS | OTHER | 411239729 | 01 |   | FEDERAL TAX | OTHER | 30701054 | 01 |   | PRIMWEST BILLING | OTHER | 6404578 | 01 |   | MEDICA | OTHER | 138399200 | 01 |   | ACS PROV | OTHER | P00082826 | 01 |   | TRAVELERS MEDICARE | OTHER |