Provider Demographics
NPI:1699014167
Name:ALLINA HEALTH SYSTEM
Entity Type:Organization
Organization Name:ALLINA HEALTH SYSTEM
Other - Org Name:ALLINA HEALTH CENTENNIAL LAKES 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:MAIL ROUTE 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 1:7373 FRANCE AVE S STE 202
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4551
Practice Address - Country:US
Practice Address - Phone:952-835-1311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC05811Medicare PIN