Basic Information
| Provider Information | |||||||||
| NPI: | 1881130417 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINNESOTA ONCOLOGY HEMATOLOGY, PA | ||||||||
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| OtherOrganizationName: | MINNESOTA ONCOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 UNIVERSITY AVE W | ||||||||
| Address2: | STE 110 N | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025311 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W CHANDLER ST | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553072127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5079642271 | ||||||||
| FaxNumber: | 5079648490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2017 | ||||||||
| LastUpdateDate: | 01/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | THEIS | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6516025326 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 1076 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1528035995 | 05 | MN | MEDICAID |