Basic Information
Provider Information | |||||||||
NPI: | 1801871934 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMERGENCY PHYSICIANS PROFESSIONAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EMERGENCY PHYSICIANS, P.A. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4300 MARKETPOINTE DRIVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554355435 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528359880 | ||||||||
FaxNumber: | 9528571554 | ||||||||
Practice Location | |||||||||
Address1: | 4300 MARKETPOINTE DRIVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554355435 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528359880 | ||||||||
FaxNumber: | 9528571554 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2005 | ||||||||
LastUpdateDate: | 03/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RENNICH | ||||||||
AuthorizedOfficialFirstName: | KRISTI | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, FINANCE | ||||||||
AuthorizedOfficialTelephone: | 9528571501 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EMERGENCY PHYSICIANS PROFESSIONAL | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7350369 | 05 | MN |   | MEDICAID | 8032100600 | 05 | MN |   | MEDICAID |