Provider Demographics
NPI:1245775642
Name:ALLINA HEALTH SYSTEM
Entity Type:Organization
Organization Name:ALLINA HEALTH SYSTEM
Other - Org Name:ALLINA HEALTH CLINIC - BUFFALO CROSSROADS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DOMINICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLARICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-222-2222
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:ROUTE 10860
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:
Practice Address - Street 1:755 CROSSROADS CAMPUS DR NE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-5074
Practice Address - Country:US
Practice Address - Phone:763-684-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC05811Medicare PIN