Basic Information
| Provider Information | |||||||||
| NPI: | 1811244809 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GROUP HEALTH PLAN INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHPARTNERS EAGAN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S | ||||||||
| Address2: | MAILSTOP 21110Q | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528837469 | ||||||||
| FaxNumber: | 9528835395 | ||||||||
| Practice Location | |||||||||
| Address1: | 1654 DIFFLEY RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516413900 | ||||||||
| FaxNumber: | 6516413920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2012 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | BJORKMAN | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9528837469 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.