Basic Information
Provider Information | |||||||||
NPI: | 1619914207 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLINA HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JOHN NASSEFF NEUROSCIENCE SPECIALTY CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2925 CHICAGO AVE | ||||||||
Address2: | ROUTE 10202 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6122621166 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 310 SMITH AVE N STE 400 | ||||||||
Address2: |   | ||||||||
City: | ST PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551022378 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512416555 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2006 | ||||||||
LastUpdateDate: | 09/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAGNUSON | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6122621020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 9806003 | 01 | MN | MEDICA SELECTCARE | OTHER | 91679 | 01 | MN | PREFERREDONE | OTHER | 355M6UN | 01 | MN | BCBS | OTHER | 126652700 | 05 | MN |   | MEDICAID | 103786 | 01 | MN | HEALTHPARTNERS | OTHER |