Basic Information
| Provider Information | |||||||||
| NPI: | 1952345639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABBOTT | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 W BROADWAY AVE | ||||||||
| Address2: | UMPHYSICIANS BROADWAY FAMILY MEDICINE | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554112504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123028200 | ||||||||
| FaxNumber: | 6123028275 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 W BROADWAY AVE | ||||||||
| Address2: | UMPHYSICIANS BROADWAY FAMILY MEDICINE | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554112504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123028200 | ||||||||
| FaxNumber: | 6123028275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 3977 | MN | X | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 3977 | MN | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100593 | 01 | MN | UCARE | OTHER | 62-55425 | 01 | MN | MEDICA CHOICE AND PRIMARY | OTHER | 1019266 | 01 | MN | PREFERRED ONE | OTHER | 37B39AB | 01 | MN | BCBS | OTHER | 767983 | 01 | MN | ARAZID | OTHER | HP27477 | 01 | MN | HEALTHPARTNERS | OTHER |