Provider Demographics
NPI:1831281146
Name:OPTUM INFUSION SERVICES 203, INC.
Entity Type:Organization
Organization Name:OPTUM INFUSION SERVICES 203, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BURR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-310-4701
Mailing Address - Street 1:11000 OPTUM CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2503
Mailing Address - Country:US
Mailing Address - Phone:800-328-5979
Mailing Address - Fax:
Practice Address - Street 1:9984 PREMIER PKWY
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025
Practice Address - Country:US
Practice Address - Phone:800-670-6922
Practice Address - Fax:855-407-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016022401Medicaid
1096723OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL016022400Medicaid
1096723OtherNCPDP PROVIDER IDENTIFICATION NUMBER