Provider Demographics
NPI:1346212313
Name:BIRKENBACH, MARK P (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:BIRKENBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 WASHINGTON AVE SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2924
Mailing Address - Country:US
Mailing Address - Phone:763-782-6400
Mailing Address - Fax:763-782-6400
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:MMC 609
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-884-0301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101224785207ZP0101X
MN261QM1300X207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA283447OtherUHC/MAMSI/MDIPA
VAPAROtherFIRST HEALTH
VA004910681Medicaid
MN57175OtherMINNESOTA MEDICAL LICENSE NUMBER
VAPAROtherVHN/PHCS
VAPAROtherMID-ATLANTIC VICARE
VA89063MTMedicaid
VAPAROtherMULTI PLAN
VA063MTOtherBC/BS NC
VA452114OtherBC/BS VA/HK
VAPAROtherCORVEL CORCARE
VA28803OtherSENTARA OHP/SHP
VAPAROtherVPH
VAPAROtherCIGNA
VAPAROtherUSA MANAGED CARE
VA008OtherCHAMPUS/TRICARE
VAPAROtherAETNA PPO
VAPAROtherUSA MANAGED CARE
VA220030510Medicare ID - Type UnspecifiedVA RR MCR
VA063MTOtherBC/BS NC
MNH400105635Medicare UPIN
VA89063MTMedicaid