Basic Information
| Provider Information | |||||||||
| NPI: | 1538334842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAIRVIEW RECOVERY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 147 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554400147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726724 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20 LAKE ST N | ||||||||
| Address2: | STE 210 | ||||||||
| City: | FOREST LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550252523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126721500 | ||||||||
| FaxNumber: | 6514644847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 01/22/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FROMM | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6126724976 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 896402500 | 05 | MN | MEDICAID |