Provider Demographics
NPI:1124210760
Name:FAIRVIEW CLINICS
Entity Type:Organization
Organization Name:FAIRVIEW CLINICS
Other - Org Name:FAIRVIEW CLINICS-ROGERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FROMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-672-4976
Mailing Address - Street 1:PO BOX 9372
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-9372
Mailing Address - Country:US
Mailing Address - Phone:612-672-6724
Mailing Address - Fax:
Practice Address - Street 1:14040 NORTHDALE BLVD
Practice Address - Street 2:STE 10
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9612
Practice Address - Country:US
Practice Address - Phone:763-488-4100
Practice Address - Fax:763-488-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN430067100Medicaid
MNC04347Medicare PIN
MNCC4080Medicare PIN
MN430067100Medicaid