Basic Information
| Provider Information | |||||||||
| NPI: | 1780794842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEETS | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | LYNN CODY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CODY | ||||||||
| OtherFirstName: | CHERYL | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 OSBORNE RD NE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632362500 | ||||||||
| FaxNumber: | 7632362795 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 OSBORNE RD NE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632362500 | ||||||||
| FaxNumber: | 7632362795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 38905 | WI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 58004 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 32353300 | 05 | WI | MEDICAID | H400175037 | 01 | MN | MEDICARE | OTHER | BD4497764658 | 05 | MN | MEDICAID |