Basic Information
Provider Information | |||||||||
NPI: | 1174537054 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANIELS | ||||||||
FirstName: | MARI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KNUDSON | ||||||||
OtherFirstName: | MARI | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6545 FRANCE AVE S | ||||||||
Address2: | SUITE 400 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554352131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529209191 | ||||||||
FaxNumber: | 9529200232 | ||||||||
Practice Location | |||||||||
Address1: | 6545 FRANCE AVE S | ||||||||
Address2: | SUITE 400 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554352131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529209191 | ||||||||
FaxNumber: | 9529200232 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 41283 | MN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 39B74DA | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 1212425 | 01 |   | MEDICA | OTHER | CP9021019450 | 01 |   | PREFERRED ONE | OTHER |