Basic Information
Provider Information | |||||||||
NPI: | 1770562779 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUGHES | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8674 | ||||||||
Address2: | MAKATO CLINIC LTD 1230 EAST MAIN STREET | ||||||||
City: | MANKATO | ||||||||
State: | MN | ||||||||
PostalCode: | 560028674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5076251811 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1230 E MAIN ST | ||||||||
Address2: | MANKATO CLINIC @ MAIN STREET | ||||||||
City: | MANKATO | ||||||||
State: | MN | ||||||||
PostalCode: | 560015066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5076251811 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2006 | ||||||||
LastUpdateDate: | 08/11/2011 | ||||||||
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 | 207Q00000X | 28520 | MN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 080067841 | 01 |   | RR MEDICARE | OTHER | 938068 | 05 | IA |   | MEDICAID | 0101162 | 01 | MN | MEDICA | OTHER | 410849339 56001 C032 | 01 |   | CHAMPUS | OTHER | NA2951023840 | 01 | MN | PREFERRED ONE | OTHER | 121158 | 01 | MN | U CARE | OTHER | HP25587 | 01 | MN | HEALTH PARTNERS | OTHER | 1566351 | 01 | MN | AMERICAS PPO | OTHER | 900873000 | 05 | MN |   | MEDICAID | 75046HU | 01 | MN | BC BS | OTHER |