Basic Information
| Provider Information | |||||||||
| NPI: | 1346212313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRKENBACH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WASHINGTON AVE SE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554142924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637826400 | ||||||||
| FaxNumber: | 7637826400 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 DELAWARE ST SE | ||||||||
| Address2: | MMC 609 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128840301 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 12/19/2013 | ||||||||
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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 | 207ZP0101X | 0101224785 | VA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0101X | 261QM1300X | MN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 283447 | 01 | VA | UHC/MAMSI/MDIPA | OTHER | PAR | 01 | VA | FIRST HEALTH | OTHER | 004910681 | 05 | VA | MEDICAID | 57175 | 01 | MN | MINNESOTA MEDICAL LICENSE NUMBER | OTHER | PAR | 01 | VA | VHN/PHCS | OTHER | PAR | 01 | VA | MID-ATLANTIC VICARE | OTHER | 89063MT | 05 | VA | MEDICAID | PAR | 01 | VA | MULTI PLAN | OTHER | 063MT | 01 | VA | BC/BS NC | OTHER | 452114 | 01 | VA | BC/BS VA/HK | OTHER | PAR | 01 | VA | CORVEL CORCARE | OTHER | 28803 | 01 | VA | SENTARA OHP/SHP | OTHER | PAR | 01 | VA | VPH | OTHER | PAR | 01 | VA | CIGNA | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER | 008 | 01 | VA | CHAMPUS/TRICARE | OTHER | PAR | 01 | VA | AETNA PPO | OTHER |