Provider Demographics
NPI:1225119175
Name:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Entity Type:Organization
Organization Name:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Other - Org Name:GILLETTE CHILDREN'S PROFESSIONAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-312-3105
Mailing Address - Street 1:200 EAST UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101
Mailing Address - Country:US
Mailing Address - Phone:651-291-2848
Mailing Address - Fax:651-325-2250
Practice Address - Street 1:200 EAST UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101
Practice Address - Country:US
Practice Address - Phone:651-291-2848
Practice Address - Fax:651-325-2250
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-18
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0578435Medicaid
MN1225119175Medicaid
WI32809900Medicaid
MN29006TEOtherBLUE CROSS & BLUE SHIELD
WI32809900Medicaid