Provider Demographics
NPI: | 1548200405 |
---|---|
Name: | ALLINA HEALTH SYSTEM |
Entity Type: | Organization |
Organization Name: | ALLINA HEALTH SYSTEM |
Other - Org Name: | ALLINA HEALTH LAKEVILLE SOUTH CLINIC |
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: | MR 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: | 20795 KEOKUK AVE |
Practice Address - Street 2: | |
Practice Address - City: | LAKEVILLE |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55044-6004 |
Practice Address - Country: | US |
Practice Address - Phone: | 952-428-0200 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-06-08 |
Last Update Date: | 2024-03-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
C05811 | Medicare PIN |