MEDICARE: GROUP HEALTH PLAN INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1053466128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROUP HEALTH PLAN INC

Provider Business Mailing Address
First Line	:	8100 34TH AVE S
Second Line	:	21113A
City	:	BLOOMINGTON
State	:	MN
Zip	:	55425-1672
Country	:	US
Telephone Number	:	952-883-5151
Fax Number	:	952-883-5160

Provider Business Practice Location Address
First Line	:	5100 GAMBLE DR
Second Line	:	STE 100
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1521
Country	:	US
Telephone Number	:	952-593-0779
Fax Number	:	952-595-6451

Authorized Official
Title or Position	:	CAO
Name	:	KATHLEEN M COONEY
Credential	:
Telephone Number	:	952-883-7565

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	08/22/2020

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