1962624437 NPI number — OCCUPATIONAL MEDICINE CONSULTANTS, LTD

Table of content: (NPI 1962624437)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962624437 NPI number — OCCUPATIONAL MEDICINE CONSULTANTS, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCCUPATIONAL MEDICINE CONSULTANTS, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1962624437
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 380
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55356-0380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-920-5663
Provider Business Mailing Address Fax Number:
952-928-9006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6515 BARRIE ROAD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-920-5663
Provider Business Practice Location Address Fax Number:
952-928-9006
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JETZER
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
952-920-5663

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com