Basic Information
| Provider Information | |||||||||
| NPI: | 1972734721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERGENCY PHYSICIANS PROFESSIONAL ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE URGENCY ROOM - WOODBURY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 MARKETPOINTE DRIVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554355435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9538359880 | ||||||||
| FaxNumber: | 9528571554 | ||||||||
| Practice Location | |||||||||
| Address1: | 7115 TAMARACK ROAD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517897000 | ||||||||
| FaxNumber: | 9528354403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2009 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RENNICH | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9528571501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMERGENCY PHYSICIANS PROFESSIONAL ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QU0200X | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 7350369 | 05 | MN | MEDICAID |