Provider Demographics
NPI:1629532429
Name:ECC ADDICTION & TOXICOLOGY SERVICES LLC
Entity Type:Organization
Organization Name:ECC ADDICTION & TOXICOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEDDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-439-1862
Mailing Address - Street 1:PO BOX 86 LOCK BOX 12-0910
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0085
Mailing Address - Country:US
Mailing Address - Phone:612-439-1862
Mailing Address - Fax:
Practice Address - Street 1:2829 UNIVERSITY AVE SE STE 730
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3279
Practice Address - Country:US
Practice Address - Phone:612-439-1862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-25
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical ToxicologyGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNPIMedicaid