Basic Information
| Provider Information | |||||||||
| NPI: | 1598717662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RASCH | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S # MS 21110Q | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8100 NORTHLAND DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554314800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528318742 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 57672501204 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207RS0010X | 11792 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 207RS0010X | 59970 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 903343 | 01 | UT | DMBA GRP 22 | OTHER | QM0000025083 | 01 | UT | ALTIUS GRP 22 | OTHER | 121126900 | 05 | UT | MEDICAID | 57672501200001 | 01 | UT | BCBS GRP 22 | OTHER | 807165900 | 05 | UT | MEDICAID | 84422 | 01 | UT | PEHP GRP 22 | OTHER | 0143327 | 05 | UT | MEDICAID | D6127 | 05 | UT | MEDICAID | 0000093458 | 01 | MT | BCBS OF MONTANA | OTHER | 100506339 | 05 | UT | MEDICAID | 90080 | 01 | UT | U HEALTH PLANS GRP22 | OTHER |