Basic Information
| Provider Information | |||||||||
| NPI: | 1518140706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW EXPRESS CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | M HEALTH FAIRVIEW CLINIC - FRIDLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9372 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554409372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726724 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6341 UNIVERSITY AVE NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554324946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725700 | ||||||||
| FaxNumber: | 7635865888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2007 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6126726594 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 21140 | 01 | MN | MEDICA EYEWARE | OTHER | 5C734CO | 01 | MN | BCBS EYEWARE | OTHER | 126906 | 01 | MN | UCARE EYEWARE | OTHER | 21-00011 | 01 | MN | EYECRAFT LAB | OTHER |