Provider Demographics
NPI: | 1528035995 |
---|---|
Name: | MINNESOTA ONCOLOGY HEMATOLOGY, PA |
Entity Type: | Organization |
Organization Name: | MINNESOTA ONCOLOGY HEMATOLOGY, PA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | DEAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GESME |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 612-884-6300 |
Mailing Address - Street 1: | 2550 UNIVERSITY AVE W |
Mailing Address - Street 2: | SUITE 110N |
Mailing Address - City: | SAINT PAUL |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55114-1052 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 651-602-5335 |
Mailing Address - Fax: | 651-665-9799 |
Practice Address - Street 1: | 2550 UNIVERSITY AVE W |
Practice Address - Street 2: | SUITE 110N |
Practice Address - City: | SAINT PAUL |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55114-1052 |
Practice Address - Country: | US |
Practice Address - Phone: | 651-602-5335 |
Practice Address - Fax: | 651-665-9799 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-03-03 |
Last Update Date: | 2016-06-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 1075 | 133V00000X |
MN | 1076 | 170300000X, 207R00000X, 207RH0000X, 207RH0003X, 207RX0202X, 207VX0201X, 2085R0001X, 208G00000X, 332B00000X, 363AM0700X, 363AS0400X, 363LA2200X, 363LF0000X, 363LG0600X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 133V00000X | Dietary & Nutritional Service Providers | Dietitian, Registered | Group - Multi-Specialty | |
No | 170300000X | Other Service Providers | Genetic Counselor, MS | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RH0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | Group - Multi-Specialty |
No | 207RX0202X | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | Group - Multi-Specialty |
No | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | Group - Multi-Specialty |
No | 2085R0001X | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | Group - Multi-Specialty |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 363LG0600X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 32881800 | Medicaid | |
MN | 896027500 | Medicaid | |
MN | 1145020008 | Medicare NSC | |
WI | 32881800 | Medicaid | |
MN | 1145020007 | Medicare NSC | |
MN | 1145020003 | Medicare NSC | |
MN | 114502005 | Medicare NSC | |
MN | 1145020001 | Medicare NSC | |
MN | 1145020002 | Medicare NSC | |
MN | C01828 | Medicare ID - Type Unspecified | GROUP MEDICARE NUMBER |