Basic Information
| Provider Information | |||||||||
| NPI: | 1215048913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GROUP HEALTH PLAN INC. | ||||||||
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| OtherOrganizationName: | HEALTHPARTNERS CENTRAL LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S | ||||||||
| Address2: | MAILSTOP 21110Q | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554401309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528837123 | ||||||||
| FaxNumber: | 9528538727 | ||||||||
| Practice Location | |||||||||
| Address1: | 9700 W 76TH ST | ||||||||
| Address2: | STE B | ||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528293390 | ||||||||
| FaxNumber: | 9528293380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | BJORKMAN | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9528837469 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 8600490 | MN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 24D0668589 | 01 | MN | CLIA | OTHER |