Basic Information
| Provider Information | |||||||||
| NPI: | 1407897309 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENNEPIN HEALTHCARE SYSTEM, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HENNEPIN COUNTY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 701 PARK AVE, P1-FINANCE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554151623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128733000 | ||||||||
| FaxNumber: | 6129044259 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 PARK AVE, P1-FINANCE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554151623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128733000 | ||||||||
| FaxNumber: | 6129044259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 03/23/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLINGS | ||||||||
| AuthorizedOfficialFirstName: | DERRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6128735340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 367063 | MN | N | Hospitals | General Acute Care Hospital | 283Q00000X | 367063 | MN | N | Hospitals | Psychiatric Hospital | 282N00000X | 331373 | MN | N | Hospitals | General Acute Care Hospital | 341600000X | 0157 | MN | N | Transportation Services | Ambulance | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 282N00000X | 367142 | MN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 64788HE | 01 | MN | BLUE SHIELD | OTHER | 06922HE | 01 | MN | BLUE SHIELD | OTHER | 1020HHE | 01 | MN | BLUE CROSS | OTHER | 157245800 | 05 | MN | MEDICAID |