Basic Information
| Provider Information | |||||||||
| NPI: | 1083692941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAIRVIEW LAKES REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 147 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554400147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726724 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5200 FAIRVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550928013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519827000 | ||||||||
| FaxNumber: | 6519827110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2006 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6126726594 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| 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 | 208M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 282N00000X | 342932 | MN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 110294 | 01 | MN | HEALTHPARTNERS | OTHER | 140045 | 01 | MN | UCARE | OTHER | 27581 | 01 | MN | HEALTHPARTNERS | OTHER | 300982 | 01 | MN | UCARE | OTHER | 5025460 | 01 | MN | MEDICA | OTHER | 1006854 | 01 | MN | PREFERREDONE | OTHER | 124637 | 01 | MN | UCARE | OTHER | 1640HDI | 01 | MN | BCBS | OTHER | 1006080 | 01 | MN | PREFERREDONE | OTHER | 468S0FA | 01 | MN | BCBS | OTHER | 792825400 | 05 | MN | MEDICAID | 9801057 | 01 | MN | MEDICA | OTHER | 19718 | 01 | MN | PREFERREDONE | OTHER | 429880 | 01 | MN | MEDICA | OTHER | 2116219 | 01 | MN | MEDICA | OTHER | 4986 | 01 | MN | PREFERREDONE | OTHER |