Basic Information
Provider Information | |||||||||
NPI: | 1437276573 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAZAKOS | ||||||||
FirstName: | ELIAS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3833 COON RAPIDS BLVD NW | ||||||||
Address2: | SUITE 100 | ||||||||
City: | COON RAPIDS | ||||||||
State: | MN | ||||||||
PostalCode: | 554332697 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7634278320 | ||||||||
FaxNumber: | 7633024338 | ||||||||
Practice Location | |||||||||
Address1: | 3833 COON RAPIDS BLVD NW | ||||||||
Address2: | SUITE 100 | ||||||||
City: | COON RAPIDS | ||||||||
State: | MN | ||||||||
PostalCode: | 554332697 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7634278320 | ||||||||
FaxNumber: | 7633024338 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2007 | ||||||||
LastUpdateDate: | 05/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 50602 | MN | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 1437276573 | 01 | MN | AMERICA'S PPO | OTHER | 0501075 | 01 | MN | MEDICA | OTHER | 1437276573 | 01 | MN | UCARE | OTHER | 1437276573 | 01 | MN | PREFERRED ONE | OTHER | 130001380 | 01 | MN | MEDICARE | OTHER | 1437276573 | 01 |   | BCBS | OTHER | 35209300 | 05 | WI |   | MEDICAID | HP97694 | 01 | MN | HEALTHPARTNERS | OTHER |