Basic Information
| Provider Information | |||||||||
| NPI: | 1649257213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADOVICH | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 GOLF COURSE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557448648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183265000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1601 GOLF COURSE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557448648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183265000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 29406 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1649257213 | 01 | UCARE | OTHER | 1649257213 | 01 | MN | PREFERRED ONE | OTHER | 1649257213 | 01 | HEALTHPARTNERS | OTHER | 1649257213 | 01 | TRICARE | OTHER | 1649257213 | 01 | WI | WI MEDICAID | OTHER | 1649257213 | 05 | MN | MEDICAID | 1649257213 | 05 | WI | MEDICAID | 597077600 | 05 | MN | MEDICAID | 0141137 | 01 | MEDICA | OTHER | 1649257213 | 01 | MN | BCBS | OTHER |