Basic Information
| Provider Information | |||||||||
| NPI: | 1770957219 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENNEPIN HEALTHCARE SYSTEM, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MVNA | ||||||||
| 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: | 2000 SUMMER ST NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554132648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126174600 | ||||||||
| FaxNumber: | 6126174782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2015 | ||||||||
| LastUpdateDate: | 03/23/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLINGS | ||||||||
| AuthorizedOfficialFirstName: | DERRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6128735340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HENNEPIN HEALTHCARE SYSTEM, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | 376132 | MN | N | Agencies | Public Health or Welfare | 251E00000X | 376132 | MN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 569253900 | 05 | MN | MEDICAID |