Basic Information
| Provider Information | |||||||||
| NPI: | 1619111705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINNESOTA ONCOLOGY HEMATOLOGY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11850 BLACKFOOT NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637122100 | ||||||||
| FaxNumber: | 7637122190 | ||||||||
| Practice Location | |||||||||
| Address1: | 11850 BLACKFOOT NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637122100 | ||||||||
| FaxNumber: | 7637122190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2009 | ||||||||
| LastUpdateDate: | 12/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | GESME | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6128846300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 170300000X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Genetic Counselor, MS | 207R00000X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RX0202X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207VX0201X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 208G00000X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 363AM0700X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363L00000X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 207RH0003X | 1076 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | C01828 | 01 | MN | MEDICARE ID | OTHER |