Healthcare Provider Details

I. General information

NPI: 1770034670
Provider Name (Legal Business Name): ALLINA HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11850 BLACKFOOT ST NW STE 405
COON RAPIDS MN
55433-2773
US

IV. Provider business mailing address

PO BOX 43 MAIL ROUTE 10585
MINNEAPOLIS MN
55440-0043
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-0888
  • Fax:
Mailing address:
  • Phone: 612-262-1166
  • Fax: 612-262-4258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DOMINICA TALLARICO
Title or Position: COO
Credential:
Phone: 612-222-2222