Basic Information
Provider Information | |||||||||
NPI: | 1851300149 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITED FAMILY PRACTICE HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNITED FAMILY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1026 W 7TH STREET | ||||||||
Address2: |   | ||||||||
City: | ST PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551023007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512411000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1026 W 7TH STREET | ||||||||
Address2: |   | ||||||||
City: | ST PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551023007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512411000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 03/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NYAKUNDI | ||||||||
AuthorizedOfficialFirstName: | ANN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6512411084 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 98256 | 01 | MN | HEALTH PARTNERS | OTHER | 282M2UN | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 164690 | 01 | MN | UCARE | OTHER | DB2459 | 01 | MN | RAILROAD MEDICARE | OTHER | NA398 | 01 | MN | PREFERRED ONE | OTHER | 620943200 | 05 | MN |   | MEDICAID |