Basic Information
Provider Information | |||||||||
NPI: | 1528167491 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILDRENS HEALTH CARE SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5901 LINCOLN DR | ||||||||
Address2: | CBC-2-REV/PE | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554361611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529925691 | ||||||||
FaxNumber: | 9529926917 | ||||||||
Practice Location | |||||||||
Address1: | 6050 CLEARWATER DRIVE | ||||||||
Address2: | CHILDRENS MTKA INDEPENDENT DIAGNOSTIC TESTING FACILITY | ||||||||
City: | MINNETONKA | ||||||||
State: | MN | ||||||||
PostalCode: | 55343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529308600 | ||||||||
FaxNumber: | 9529308650 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2006 | ||||||||
LastUpdateDate: | 10/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCORMICK | ||||||||
AuthorizedOfficialFirstName: | BRENDA LU | ||||||||
AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
AuthorizedOfficialTitleorPosition: | SR. VP AND CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6128136129 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | 331022 | MN | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
ID | Type | State | Issuer | Description | 847979800 | 05 | MN |   | MEDICAID |