Basic Information
Provider Information | |||||||||
NPI: | 1760589170 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLUMBIA PARK MEDICAL GROUP, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BROOKLYN PARK - EYEWARE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6401 UNIVERSITY AVE NE | ||||||||
Address2: |   | ||||||||
City: | FRIDLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554324341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635725710 | ||||||||
FaxNumber: | 7635713008 | ||||||||
Practice Location | |||||||||
Address1: | 10000 ZANE AVE N | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN PARK | ||||||||
State: | MN | ||||||||
PostalCode: | 554431400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635725710 | ||||||||
FaxNumber: | 7635696200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 11/13/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONDON | ||||||||
AuthorizedOfficialFirstName: | JOEN | ||||||||
AuthorizedOfficialMiddleName: | V | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7635865839 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COLUMBIA PARK MEDICAL GROUP, PA | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   | MN | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
ID Information
ID | Type | State | Issuer | Description | 5C727CO | 01 | MN | BCBS EYEWARE | OTHER | 102326 | 01 | MN | UCARE EYEWARE | OTHER | 21-08316 | 01 | MN | EYECRAFT LAB | OTHER | 08316 | 01 | MN | MEDICA EYEWARE | OTHER |