Basic Information
Provider Information | |||||||||
NPI: | 1255549978 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARMODY | ||||||||
FirstName: | SHARON | ||||||||
MiddleName: | SWEENEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SWEENEY | ||||||||
OtherFirstName: | SHARON | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7301 OHMS LANE | ||||||||
Address2: | SUITE 650 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 55439 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528359880 | ||||||||
FaxNumber: | 9528571554 | ||||||||
Practice Location | |||||||||
Address1: | 4050 COON RAPIDS BLVD | ||||||||
Address2: | MERCY MEDICAL CENTER | ||||||||
City: | COON RAPIDS | ||||||||
State: | MN | ||||||||
PostalCode: | 55433 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7632367144 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 49289 | MN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | FC0121929 | 01 | MN | DEA | OTHER | 49289 | 01 | MN | MEDICAL LICENSE | OTHER |