Basic Information
| Provider Information | |||||||||
| NPI: | 1639262785 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDRENS HEALTH CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDRENS HOSPITALS AND CLINICS OF MINNESOTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 LINCOLN DRIVE, CBC-2-REV/PE | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554361611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529925398 | ||||||||
| FaxNumber: | 9529926917 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 NORTH SMITH AVENUE | ||||||||
| Address2: | CHILDRENS HOSPITALS AND CLINICS EMERGENCY PHYSICIANS | ||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512206914 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | OSTENDORF | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | RAYMOND | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6128136129 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | 331019 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
| ID | Type | State | Issuer | Description | 141847500 | 05 | MN | MEDICAID |