Basic Information
| Provider Information | |||||||||
| NPI: | 1730495003 | ||||||||
| 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: | 715 E 78TH ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554201397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128737644 | ||||||||
| FaxNumber: | 9528541272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2010 | ||||||||
| LastUpdateDate: | 10/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | KRYZANIAK | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6128739290 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 367063 | MN | N | Ambulatory Health Care Facilities | Clinic/Center | 261Q00000X | 367142 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 157245800 | 05 | MN | MEDICAID |