1023190543 NPI number — DR. DAVID W MACOMBER MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023190543 NPI number — DR. DAVID W MACOMBER MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MACOMBER

Provider First Name:

DAVID

Provider Middle Name:

W

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1023190543

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

10/26/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

420 DELAWARE STREET SE, MMC 741

Provider Second Line Business Mailing Address:

UNIVERSITY OF MINNESOTA PHYSICIANS

Provider Business Mailing Address City Name:

MINNEAPOLIS

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

55455

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

612-884-0999

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

516 DELAWARE STREET SE, CLINIC 3A

Provider Second Line Business Practice Location Address:

UNIVERSITY OF MINNESOTA PHYSICIANS

Provider Business Practice Location Address City Name:

MINNEAPOLIS

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

55455

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

612-884-0999

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

10/20/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  41985 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 826567400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 04-02892 . This is a "MEDICA CHOICE" identifier . This identifiers is of the category "OTHER".
• Identifier: 0539502 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 110A7MA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 128141 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: HP40352 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
• Identifier: 1028590 . This is a "PREFERREDONE" identifier . This identifiers is of the category "OTHER".
• Identifier: 10387 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
• Identifier: 34069000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 04-00123 . This is a "MEDICA PRIMARY" identifier . This identifiers is of the category "OTHER".
• Identifier: 1353467 . This is a "ARAZ" identifier . This identifiers is of the category "OTHER".
• Identifier: 7777470 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".