Basic Information
| Provider Information | |||||||||
| NPI: | 1891802989 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | CLAYTON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125650 | ||||||||
| Practice Location | |||||||||
| Address1: | 4010 W 65TH ST | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524567000 | ||||||||
| FaxNumber: | 9524567001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | 32128 | MN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 73B07DI | 01 | BLUE CROSS BLUE SHIELD | OTHER | 969991000407 | 01 | PREFERREDONE | OTHER | 911931 | 01 | MEDICA | OTHER | HP13159 | 01 | HEALTHPARTNERS | OTHER | 699363000 | 05 | MN | MEDICAID | 102891E948 | 01 | UCARE | OTHER |