Provider Demographics
NPI:1730495003
Name:HENNEPIN HEALTHCARE SYSTEM, INC
Entity Type:Organization
Organization Name:HENNEPIN HEALTHCARE SYSTEM, INC
Other - Org Name:HENNEPIN COUNTY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KRYZANIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-873-9290
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:P1-FINANCE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-3000
Mailing Address - Fax:612-904-4259
Practice Address - Street 1:715 E 78TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1397
Practice Address - Country:US
Practice Address - Phone:612-873-7644
Practice Address - Fax:952-854-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN367063261Q00000X
MN367142261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN157245800Medicaid
MNC04460Medicare PIN
MNC01999Medicare PIN
MN240004Medicare Oscar/Certification
MN157245800Medicaid