Basic Information
| Provider Information | |||||||||
| NPI: | 1871715136 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH MEMORIAL HEALTH CARE | ||||||||
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| OtherOrganizationName: | NORTH MEMORIAL HEALTH MENTAL HEALTH & ADDICTION CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 OAKDALE AVE N | ||||||||
| Address2: | |||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635205200 | ||||||||
| FaxNumber: | 7635814561 | ||||||||
| Practice Location | |||||||||
| Address1: | 3366 OAKDALE AVE N | ||||||||
| Address2: | |||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635205200 | ||||||||
| FaxNumber: | 7635201534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | FROMM | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 7635814614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH MEMORIAL HEALTH CARE | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 364SP0808X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 103TP0016X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
ID Information
| ID | Type | State | Issuer | Description | 137026 | 01 | UCARE | OTHER | 100917 | 01 | HEALTH PARTNERS | OTHER | 83G83NO | 01 | BLUE CROSS | OTHER | 69820 | 01 | PREFERRED ONE | OTHER |