Basic Information
Provider Information | |||||||||
NPI: | 1619920568 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORT | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 710 COMMERCE DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | WOODBURY | ||||||||
State: | MN | ||||||||
PostalCode: | 551254925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6519685904 | ||||||||
FaxNumber: | 6519685904 | ||||||||
Practice Location | |||||||||
Address1: | 3580 ARCADE ST | ||||||||
Address2: |   | ||||||||
City: | VADNAIS HEIGHTS | ||||||||
State: | MN | ||||||||
PostalCode: | 551277135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6519685770 | ||||||||
FaxNumber: | 6519685775 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 07/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 6064 | MN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
ID | Type | State | Issuer | Description | 1619920568 | 05 | MN |   | MEDICAID | 65001461 | 01 | MN | MEDICARE PROVIDER NUMBER | OTHER | P00408766 | 01 | MN | RAILROAD MEDICARE | OTHER |