Basic Information
| Provider Information | |||||||||
| NPI: | 1013994359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY OF MN MEDICAL CENTER, FAIRVIEW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 147 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554400147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726724 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2450 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726000 | ||||||||
| FaxNumber: | 6122734098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6126726594 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207ZP0105X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 282N00000X | 00200 | MN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1012HRI | 01 | MN | BCBS | OTHER | 3M361FA | 01 | MN | BCBS | OTHER | 590615600 | 05 | MN | MEDICAID | 616845167 | 05 | MN | MEDICAID | 684137000 | 05 | MN | MEDICAID | 35A80FA | 01 | MN | BCBS | OTHER | 712649200 | 05 | MN | MEDICAID | 265497100 | 05 | MN | MEDICAID | 616845100 | 05 | MN | MEDICAID | 1012RRI | 01 | MN | BCBS | OTHER | 616845102 | 05 | MN | MEDICAID | 758355900 | 05 | MN | MEDICAID | 896402500 | 05 | MN | MEDICAID | 1012PRI | 01 | MN | BCBS | OTHER | 170128200 | 05 | MN | MEDICAID | 055755200 | 05 | MN | MEDICAID | 339R1FA | 01 | MN | BCBS | OTHER | 387355200 | 05 | MN | MEDICAID |