Provider Demographics
NPI:1134173644
Name:FAIRMONT ORTHOPEDICS & SPORTS MEDICINE, PA
Entity type:Organization
Organization Name:FAIRMONT ORTHOPEDICS & SPORTS MEDICINE, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE MANAGER ADMIN AP
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-238-4949
Mailing Address - Street 1:717 S STATE ST STE 900
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4400
Mailing Address - Country:US
Mailing Address - Phone:507-238-4949
Mailing Address - Fax:507-238-3365
Practice Address - Street 1:717 S STATE ST
Practice Address - Street 2:SUITE 900
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4469
Practice Address - Country:US
Practice Address - Phone:507-238-4949
Practice Address - Fax:507-238-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Multi-Specialty
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB1729OtherRAILROAD MEDICARE
MN29D51FAOtherBLUE CROSS BLUE SHIELD CHIROPRACTIC
112399OtherUCARE
27084OtherSANFORD HEALTH
MN590024700Medicaid
974311025203OtherPREF ONE
MN40645WEOtherBLUE CROSS BLUE SHIELD
09809248OtherMEDICA
MN396G2PROtherBLUE CROSS BLUE SHIELD
138808700OtherUS DEPT OF LABOR
29394OtherHEALTHPARTNERS
MN40645WEOtherBLUE CROSS BLUE SHIELD
112399OtherUCARE
MN29D51FAOtherBLUE CROSS BLUE SHIELD CHIROPRACTIC
IAI14168Medicare PIN