Basic Information
| Provider Information | |||||||||
| NPI: | 1487645537 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DENNIS | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD, MPH, FAAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | SUITE #1300 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | SUITE #1300 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208000000X | 24057 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | SHP50A90DE | 01 | BLUE CROSS BLUE SHIELD | OTHER | 556146 | 01 | ARAZ GROUP AMERICAS PPO | OTHER | 254009 | 01 | PREFERRED ONE | OTHER | 110408 | 01 | U CARE | OTHER | 1123622 | 01 | FIRST HEALTH PLAN | OTHER | 51A32DE | 01 | BLUE CROSS BLUE SHIELD | OTHER | 1202199 | 01 | MEDICA HEALTH PLANS | OTHER | HP25415 | 01 | HEALTH PARTNERS | OTHER |