Basic Information
Provider Information | |||||||||
NPI: | 1891990404 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RATHMANN | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | ALLAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2355 HIGHWAY 36 W STE 100 | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 551133905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512922000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2355 HIGHWAY 36 W STE 100 | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 551133905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512922000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2007 | ||||||||
LastUpdateDate: | 07/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 50112 | MN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | HP78435 | 01 | MN | HEALTH PARTNERS | OTHER | P00406914 | 01 | MN | RAILROAD MEDICARE | OTHER | 134436 | 01 | MN | UCARE | OTHER | 34911200 | 05 | WI |   | MEDICAID | 1891990404 | 01 | MN | AMERICA'S PPO | OTHER | 300004211 | 01 | MN | MEDICARE | OTHER | 960371004676 | 01 | MN | PREFERRED ONE | OTHER | 16-04895 | 01 | MN | MEDICA | OTHER | 170453000 | 05 | MN |   | MEDICAID | 1891990404 | 05 | MN |   | MEDICAID | 6G394RA | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 300004210 | 01 | MN | MEDICARE | OTHER |