Basic Information
| Provider Information | |||||||||
| NPI: | 1730586819 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY OF MINNESOTA HEALTH NURSE PRACTITIONERS-A UMPHYSICIANS CLIN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6300 SHINGLE CREEK PARKWAY | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | BROOKLYN CENTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554302127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637826400 | ||||||||
| FaxNumber: | 7637829558 | ||||||||
| Practice Location | |||||||||
| Address1: | 814 SOUTH 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128889792 | ||||||||
| FaxNumber: | 6128889762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2014 | ||||||||
| LastUpdateDate: | 12/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6128840802 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | COO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | C02390 | 01 | MN | MEDICARE PTAN | OTHER |