Provider Demographics
NPI: | 1629044029 |
---|---|
Name: | MANKATO CLINIC, LTD. |
Entity Type: | Organization |
Organization Name: | MANKATO CLINIC, LTD. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | RANDY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | FARROW |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 507-389-8501 |
Mailing Address - Street 1: | PO BOX 8674 |
Mailing Address - Street 2: | |
Mailing Address - City: | MANKATO |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 56002-8674 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 800-657-6944 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1230 E MAIN ST |
Practice Address - Street 2: | |
Practice Address - City: | MANKATO |
Practice Address - State: | MN |
Practice Address - Zip Code: | 56001-5066 |
Practice Address - Country: | US |
Practice Address - Phone: | 800-657-6944 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-02-24 |
Last Update Date: | 2016-11-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 1107 | Other | HEALTH PARTNERS |
MN | 111843 | Other | UCARE MN |
MN | 396510400 | Medicaid | |
MN | 41411MA | Other | BLUE CROSS MN |
MN | 1107 | Other | HEALTH PARTNERS |
MN | CO0026 | Medicare PIN | |
MN | 396510400 | Medicaid | |
MN | 0378330001 | Medicare NSC |