Basic Information
| Provider Information | |||||||||
| NPI: | 1598857005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERHEIDEN | ||||||||
| FirstName: | TERENCE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207632540 | ||||||||
| FaxNumber: | 3207635749 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207632540 | ||||||||
| FaxNumber: | 3207635749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 2219 | MA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 808 | MN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 000E46150 | 05 | CA | MEDICAID | 1598857005 | 05 | MN | MEDICAID | 454788 | 01 | CA | INTERPLAN | OTHER | 000810816204 | 01 | CA | PHCS | OTHER | 1598857005 | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 2481192 | 01 | CA | UNITED HEALTHCARE | OTHER | 0309120 | 01 | CA | CIGNA | OTHER | E4615 | 01 | CA | BLUE CROSS | OTHER | 5716593 | 01 | CA | FIRST HEALTH | OTHER | 0027-0001472 | 01 | MN | MEDICA | OTHER | 90197471 | 01 | CA | PACIFICARE | OTHER | MCMG488100 | 01 | CA | WESTERN HEALTH ADVANTAGE | OTHER | 110834 | 01 | CA | HEALTH NET | OTHER | 1904853 | 01 | CA | GREAT WEST | OTHER | 7637749 | 01 | CA | AETNA | OTHER |