Basic Information
| Provider Information | |||||||||
| NPI: | 1811077175 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY OF MN MEDICAL CENTER, FAIRVIEW - PHYSICIANS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9372 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554409372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726724 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2450 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726000 | ||||||||
| FaxNumber: | 6122734098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6126726594 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 364S00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 207P00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6D402FA | 01 | MN | BCBS | OTHER | 017945000 | 05 | MN | MEDICAID | 3903728 | 01 | MN | MEDICA | OTHER | 120337 | 01 | MN | UCARE | OTHER | 42961 | 01 | MN | PREFERREDONE | OTHER | 46773 | 01 | MN | HEALTHPARTNERS | OTHER | 28156 | 01 | MN | HEALTHPARTNERS | OTHER | 300050 | 01 | MN | UCARE | OTHER | 97455 | 01 | MN | PREFERREDONE | OTHER | 35A82FA | 01 | MN | BCBS | OTHER | 73773 | 01 | MN | HEALTHPARTNERS | OTHER | 9846053 | 01 | MN | MEDICA | OTHER | 400059 | 01 | MN | UCARE | OTHER | 4600879 | 01 | MN | MEDICA | OTHER | 4700034 | 01 | MN | MEDICA | OTHER | 62531 | 01 | MN | PREFERREDONE | OTHER | 9839168 | 01 | MN | MEDICA | OTHER |