Basic Information
Provider Information | |||||||||
NPI: | 1629004916 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH MEMORIAL HEALTH CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTH MEMORIAL HEALTH CLINIC - ELK RIVER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 FREEPORT AVE NW | ||||||||
Address2: |   | ||||||||
City: | ELK RIVER | ||||||||
State: | MN | ||||||||
PostalCode: | 553302723 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635812273 | ||||||||
FaxNumber: | 7635815201 | ||||||||
Practice Location | |||||||||
Address1: | 800 FREEPORT AVE NW STE 100 | ||||||||
Address2: |   | ||||||||
City: | ELK RIVER | ||||||||
State: | MN | ||||||||
PostalCode: | 553302723 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635812273 | ||||||||
FaxNumber: | 7635815201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2006 | ||||||||
LastUpdateDate: | 04/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FROMM | ||||||||
AuthorizedOfficialFirstName: | DAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP, CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7635814614 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NORTH MEMORIAL HEALTH CARE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | 69814 | 01 |   | HEALTH PARTNERS | OTHER | 129793 | 01 |   | UCARE | OTHER | 9800016 | 01 |   | MEDICA | OTHER | 88D55EL | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | NM101 | 01 |   | PREFERRED ONE | OTHER |