Provider Demographics
NPI:1063459485
Name:HENNEPIN FACULTY ASSOCIATES
Entity Type:Organization
Organization Name:HENNEPIN FACULTY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:FOSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-347-5109
Mailing Address - Street 1:914 S 8TH ST
Mailing Address - Street 2:S600
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 S 8TH ST
Practice Address - Street 2:S4
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1210
Practice Address - Country:US
Practice Address - Phone:612-347-6450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN142712100Medicaid
MN142712100Medicaid