Basic Information
Provider Information | |||||||||
NPI: | 1720098064 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSON | ||||||||
FirstName: | JADE | ||||||||
MiddleName: | GARRETT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2550 UNIVERSITY AVE W STE 110N | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551142001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6516025309 | ||||||||
FaxNumber: | 6512226786 | ||||||||
Practice Location | |||||||||
Address1: | 480 OSBORNE RD NE | ||||||||
Address2: | SUITE 220 | ||||||||
City: | FRIDLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554322773 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7637861620 | ||||||||
FaxNumber: | 7637803099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2006 | ||||||||
LastUpdateDate: | 02/21/2018 | ||||||||
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 | 207RX0202X | 42135 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | HP32508 | 01 | MN | HEALTH PARTNERS | OTHER | 946423900 | 05 | MN |   | MEDICAID | 963001032272 | 01 | MN | PREFERRED ONE | OTHER | 3600554 | 01 | MN | SELECT CARE | OTHER | 3600554 | 01 | MN | 3600554 | OTHER | 500T4AN | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 143482 | 01 | MN | UCARE | OTHER |