Basic Information
| Provider Information | |||||||||
| NPI: | 1255394573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIRKS | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 EXCELSIOR BLVD STE 160 | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554264713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529937700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6600 EXCELSIOR BLVD STE 160 | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529937700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 43635 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 256R4DI | 01 | MN | BCBS OF MN | OTHER | 171376 | 01 | MN | UCARE MN | OTHER | 116678600 | 05 | MN | MEDICAID | 6605843 | 01 | MN | MEDICA UC | OTHER | 0113366 | 01 | MN | MEDICA | OTHER | 1029313 | 01 | MN | PREFERRED ONE | OTHER | HP38689 | 01 | MN | HEALTHPARTNERS | OTHER | 1796988 | 01 | MN | AMERICA'S PPO | OTHER | 7402476 | 01 | MN | AETNA | OTHER |