1679673073 NPI number — BRUCE GEORGE DAHLMAN P.T.

Table of content: BRUCE GEORGE DAHLMAN P.T. (NPI 1679673073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679673073 NPI number — BRUCE GEORGE DAHLMAN P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAHLMAN
Provider First Name:
BRUCE
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1679673073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6401 UNIVERSITY AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRIDLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55432-4341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-572-5710
Provider Business Mailing Address Fax Number:
763-571-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10961 CLUB WEST PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLAINE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55449-4671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-572-5710
Provider Business Practice Location Address Fax Number:
763-528-2945
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  1600 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 6746 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6405049 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 374L6DA . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP47868 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1250543 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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