Basic Information
Provider Information | |||||||||
NPI: | 1477819985 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VARGO | ||||||||
FirstName: | ADRIENNE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 166 4TH ST. E. | ||||||||
Address2: | STE. 100 | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 55101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512922000 | ||||||||
FaxNumber: | 6512922136 | ||||||||
Practice Location | |||||||||
Address1: | 250 THOMPSON ST | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 55102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512922000 | ||||||||
FaxNumber: | 6512922136 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2012 | ||||||||
LastUpdateDate: | 01/04/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036129982 | IL | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD448781 | PA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 64788 | MN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.