Basic Information
| Provider Information | |||||||||
| NPI: | 1457657256 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLINA HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | ALLINA HEALTH WEIGHT MANAGEMENT-MERCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | MR 10202 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122621166 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11850 BLACKFOOT ST NW STE 130 | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632362045 | ||||||||
| FaxNumber: | 7632362044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2011 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAGNUSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6122620102 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 2083B0002X | N | 193200000X MULTI-SPECIALTY GROUP | 207QB0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Bariatric Medicine |
No ID Information.