Basic Information
| Provider Information | |||||||||
| NPI: | 1548802317 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GROUP HEALTH PLAN, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WELL@WORK CLINIC MET COUNCIL HEYWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S # MS 21110Q | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528837469 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 560 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554114332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529677468 | ||||||||
| FaxNumber: | 9528311060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2019 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BJORKMAN | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9528837469 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.