Basic Information
Provider Information | |||||||||
NPI: | 1174591770 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCFADDEN | ||||||||
FirstName: | RODNEY | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17400 80TH AVE N | ||||||||
Address2: |   | ||||||||
City: | MAPLE GROVE | ||||||||
State: | MN | ||||||||
PostalCode: | 553114704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7634161649 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 701 25TH AVE S | ||||||||
Address2: | SUITE 505 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554541513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6124552040 | ||||||||
FaxNumber: | 6124552009 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2006 | ||||||||
LastUpdateDate: | 10/18/2010 | ||||||||
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 | 207R00000X | 37756 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 428813100 | 05 | MN |   | MEDICAID |