Basic Information
| Provider Information | |||||||||
| NPI: | 1902414378 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW EXPRESS CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | M HEALTH FAIRVIEW LAKES MEDICAL CENTER (SPECIALTY BILLING ) | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 400 STINSON BLVD | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554132613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126722258 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5200 FAIRVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550928013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519827000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2020 | ||||||||
| LastUpdateDate: | 07/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6126726594 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.