Healthcare Provider Details

I. General information

NPI: 1427243484
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF MINNESOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 PILLSBURY DR SE
MINNEAPOLIS MN
55455-0279
US

IV. Provider business mailing address

164 PILLSBURY DR SE
MINNEAPOLIS MN
55455-0279
US

V. Phone/Fax

Practice location:
  • Phone: 612-624-3322
  • Fax: 612-624-7586
Mailing address:
  • Phone: 612-624-3322
  • Fax: 612-624-7586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number5987
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5987
License Number StateMN

VIII. Authorized Official

Name: DR. MARK DERUITER
Title or Position: PROGRAM DIRECTOR
Credential: PHD
Phone: 612-624-3322