Basic Information
| Provider Information | |||||||||
| NPI: | 1215229729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIDOR | ||||||||
| FirstName: | SHANNA | ||||||||
| MiddleName: | RACHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANDGREN | ||||||||
| OtherFirstName: | SHANNA | ||||||||
| OtherMiddleName: | RACHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5219 ST JOHN DRIVE | ||||||||
| Address2: | |||||||||
| City: | NETT LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557728232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187573295 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5219 ST JOHN DRIVE | ||||||||
| Address2: | |||||||||
| City: | NETT LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557728232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187573295 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2011 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 55689 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1215229729 | 05 | MN | MEDICAID | P01105126 | 01 | MN | RAILROAD MEDICARE | OTHER | 1215229729 | 01 | MEDICA | OTHER | 1215229729 | 01 | MN | BCBS | OTHER |