Provider Demographics
NPI:1033107230
Name:BRADLEY W NEUJAHR OD PA
Entity Type:Organization
Organization Name:BRADLEY W NEUJAHR OD PA
Other - Org Name:NORTHWEST EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:NEUJAHR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-435-1010
Mailing Address - Street 1:111 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-1301
Mailing Address - Country:US
Mailing Address - Phone:218-435-1010
Mailing Address - Fax:218-435-1715
Practice Address - Street 1:111 2ND ST NE
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1301
Practice Address - Country:US
Practice Address - Phone:218-435-1010
Practice Address - Fax:218-435-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1892152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116599OtherMEDICARE - U CARE
410004074OtherRR MEDICARE
050601001OtherMETROPOLITAN HEALTH PLAN
63309FOOtherBCBS BLUE PLUS MATERIALS
MN116599Medicaid
982601006692OtherPREFERRED ONE
63235NEOtherBCBS OF MN FACILITY
63585NEOtherBCBS OF MN INDIVIDUAL DR
MN137823600Medicaid
22 24063OtherMEDICA
22 24063OtherMEDICA
410004074OtherRR MEDICARE
22 24063OtherMEDICA
419000732Medicare ID - Type Unspecified
MN0221320002Medicare NSC