Basic Information
| Provider Information | |||||||||
| NPI: | 1902850159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIRNBAUM | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880661 | ||||||||
| FaxNumber: | 7632872310 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880661 | ||||||||
| FaxNumber: | 7632872310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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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 | 2084N0400X | 23916 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | HP21939 | 01 | MN | HEALTHPARTNERS | OTHER | 0507277 | 01 | MN | MEDICA | OTHER | 1008983 | 01 | MN | PREFERRED ONE | OTHER | 765068 | 01 | MN | AMERICA'S PPO | OTHER | 30228900 | 05 | WI | MEDICAID | 36B41BI | 01 | MN | BCBS OF MN | OTHER |