Basic Information
| Provider Information | |||||||||
| NPI: | 1811923097 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH MEMORIAL HEALTH CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH MEMORIAL HEALTH CLINIC - BROOKLYN PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8559 EDINBROOK PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BROOKLYN PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554433728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635812273 | ||||||||
| FaxNumber: | 7635815661 | ||||||||
| Practice Location | |||||||||
| Address1: | 8559 EDINBROOK PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BROOKLYN PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554433728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635812273 | ||||||||
| FaxNumber: | 7635815661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 09/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | FROMM | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 7635814614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH MEMORIAL HEALTH CARE | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | NM100 | 01 | PREFERRED ONE | OTHER | 107337 | 01 | UCARE | OTHER | 40439NO | 01 | MN | BCBS | OTHER | 9801701 | 01 | MEDICA | OTHER | 11207 | 01 | HEALTH PARTNERS | OTHER |