Basic Information
Provider Information | |||||||||
NPI: | 1639543036 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HENNEPIN HEALTHCARE SYSTEM, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HENNEPIN HEALTHCARE HOSPICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 701 PARK AVE | ||||||||
Address2: | P1-FINANCE | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554151623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6128733000 | ||||||||
FaxNumber: | 6129044259 | ||||||||
Practice Location | |||||||||
Address1: | 2000 SUMMER ST NE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554132648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635312424 | ||||||||
FaxNumber: | 7635312422 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2015 | ||||||||
LastUpdateDate: | 10/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLLINGS | ||||||||
AuthorizedOfficialFirstName: | DERRICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6128735340 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HENNEPIN HEALTHCARE SYSTEM, INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 369767 | MN | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 194092900 | 05 | MN |   | MEDICAID |