Basic Information
Provider Information | |||||||||
NPI: | 1770123697 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MINNESOTA ONCOLOGY HEMATOLOGY, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
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: | 6516025335 | ||||||||
FaxNumber: | 6516659799 | ||||||||
Practice Location | |||||||||
Address1: | 1580 BEAM AVE | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551091127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6517797978 | ||||||||
FaxNumber: | 6517797656 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2020 | ||||||||
LastUpdateDate: | 01/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THEIS | ||||||||
AuthorizedOfficialFirstName: | JOAN | ||||||||
AuthorizedOfficialMiddleName: | LOUISE | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6516025326 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.