1831178623 NPI number — RYAN J BORTOLON M.D.

Table of content: RYAN J BORTOLON M.D. (NPI 1831178623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831178623 NPI number — RYAN J BORTOLON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORTOLON
Provider First Name:
RYAN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1831178623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 209036
Provider Second Line Business Mailing Address:
SHRINERS HOSPITALS FOR CHILDREN TWIN CITIES
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-9036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-281-8478
Provider Business Mailing Address Fax Number:
813-281-8113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 E RIVER PARKWAY
Provider Second Line Business Practice Location Address:
SHRINERS HOSPITALS FOR CHILDREN TWIN CITIES
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55414-3604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-596-6187
Provider Business Practice Location Address Fax Number:
612-339-7634
Provider Enumeration Date:
01/11/2006

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: 207L00000X , with the licence number:  46172 , 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: 380440200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".