Basic Information
| Provider Information | |||||||||
| NPI: | 1528361573 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENNEPIN HEALTHCARE SYSTEM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HENNEPIN COUNTY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 PARK AVE | ||||||||
| Address2: | P1-FINANCE | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554151623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128733000 | ||||||||
| FaxNumber: | 6129044259 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S 6TH ST | ||||||||
| Address2: | GOVERNMENT CENTER-A 120 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554870070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123484628 | ||||||||
| FaxNumber: | 6125969984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2010 | ||||||||
| LastUpdateDate: | 03/23/2017 | ||||||||
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| AuthorizedOfficialLastName: | HOLLINGS | ||||||||
| AuthorizedOfficialFirstName: | DERRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.F.O | ||||||||
| AuthorizedOfficialTelephone: | 6128735340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 367142 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 157245800 | 05 | MN | MEDICAID |