Basic Information
Provider Information | |||||||||
NPI: | 1629280995 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IDRISS | ||||||||
FirstName: | REEDADA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | IDRISS | ||||||||
OtherFirstName: | REED | ||||||||
OtherMiddleName: | S | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 5120 DUVALL PL NW | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | MN | ||||||||
PostalCode: | 559013821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5072871831 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 24 HOSPITAL AVE | ||||||||
Address2: |   | ||||||||
City: | DANBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 068106099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037397000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/07/2007 | ||||||||
LastUpdateDate: | 06/02/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 49753 | MN | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 047400 | CT | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 297122100 | 05 | MN |   | MEDICAID | 35174100 | 05 | WI |   | MEDICAID | ENROLLED | 05 | IA |   | MEDICAID |