Basic Information
Provider Information | |||||||||
NPI: | 1902989239 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CROSSROADS MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CROSSROADS SHACKOPEE A | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1335 10TH AVE E | ||||||||
Address2: |   | ||||||||
City: | SHAKOPEE | ||||||||
State: | MN | ||||||||
PostalCode: | 553792901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1335 10TH AVE E | ||||||||
Address2: |   | ||||||||
City: | SHAKOPEE | ||||||||
State: | MN | ||||||||
PostalCode: | 553792901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9524966700 | ||||||||
FaxNumber: | 9524456448 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHACKELFORD | ||||||||
AuthorizedOfficialFirstName: | DIRENDIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGED CARE SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 8006540889 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 27079 | MN | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
ID Information
ID | Type | State | Issuer | Description | 2423692 | 01 |   | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |