Provider Demographics
NPI:1891762993
Name:HAEFEMEYER, JAMES W (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:HAEFEMEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 RIVERSIDE AVE
Mailing Address - Street 2:21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1321
Mailing Address - Country:US
Mailing Address - Phone:612-371-1600
Mailing Address - Fax:612-371-1732
Practice Address - Street 1:2220 RIVERSIDE AVE
Practice Address - Street 2:21110Q
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1321
Practice Address - Country:US
Practice Address - Phone:612-371-1600
Practice Address - Fax:612-371-1732
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN484203100Medicaid
D98171Medicare UPIN
MN484203100Medicaid