Provider Demographics
NPI:1598824880
Name:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Entity Type:Organization
Organization Name:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Other - Org Name:GILLETTE CHILDREN'S HEALTHCARE MNTK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-312-3105
Mailing Address - Street 1:200 UNIVERSITY AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2507
Mailing Address - Country:US
Mailing Address - Phone:651-291-2848
Mailing Address - Fax:651-325-2174
Practice Address - Street 1:6060 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9442
Practice Address - Country:US
Practice Address - Phone:952-936-0977
Practice Address - Fax:952-936-0944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QM1300X, 332B00000X, 332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN594130000Medicaid
WI41683100Medicaid
MN815488000Medicaid
1111HGIOtherBLUE CROSS BLUE SHIELD
WI11003700Medicaid
MN815488000Medicaid
1111HGIOtherBLUE CROSS BLUE SHIELD
=========OtherCOMMERCIAL