Provider Demographics
NPI:1407833643
Name:FAIRVIEW HEALTH SERVICES
Entity Type:Organization
Organization Name:FAIRVIEW HEALTH SERVICES
Other - Org Name:UNIVERSITY OF MN MEDICAL CENTER, FAIRVIEW RENAL DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR NETWORK RELATIONS AO
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-672-6740
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0147
Mailing Address - Country:US
Mailing Address - Phone:612-672-6724
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:SUITE C2300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-365-2300
Practice Address - Fax:612-365-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02098261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN616845106Medicaid
MN1006055OtherPREFERREDONE
MN5000803OtherMEDICA
MN1012HRIOtherBCBS
MN2OtherHEALTHPARTNERS
MN300050OtherUCARE
MN616845106Medicaid