Basic Information
| Provider Information | |||||||||
| NPI: | 1639125503 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHEAST MEDICAL RESEARCH INSTITUTE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHEAST VADNAIS HEIGHTS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 CENTERVILLE CIR | ||||||||
| Address2: | |||||||||
| City: | VADNAIS HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551275033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513265900 | ||||||||
| FaxNumber: | 6514268935 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 CENTERVILLE CIR | ||||||||
| Address2: | |||||||||
| City: | VADNAIS HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551275033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513265900 | ||||||||
| FaxNumber: | 6514268935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 06/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6126726594 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTHEAST MEDICAL RESEARCH INSTITUTE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0841630003 | 01 | MN | MEDICARE PTAN | OTHER | 591013700 | 05 | MN | MEDICAID |