Basic Information
Provider Information | |||||||||
NPI: | 1578507513 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLINA HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RIVER FALLS PROFESSIONAL SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2925 CHICAGO AVE | ||||||||
Address2: | MR 10202 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6122621166 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1629 E DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | RIVER FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 540221571 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7153076000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2006 | ||||||||
LastUpdateDate: | 09/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAGNUSON | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6122621020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 367500000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 207P00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 32770700 | 05 | WI |   | MEDICAID | 36201400 | 05 | WI |   | MEDICAID | 985350000212 | 01 | MN | PREFERREDONE | OTHER | 619553900 | 05 | MN |   | MEDICAID | 94526 | 01 |   | HEALTHPARTNERS | OTHER | 0114812 | 01 | MN | MEDICA SELECTCARE | OTHER | 3944484 | 01 | MN | MEDICA CHOICE | OTHER | 3T051RI | 01 |   | BCBS | OTHER | 41229000 | 05 | WI |   | MEDICAID | 43415300 | 05 | WI |   | MEDICAID |