Healthcare Provider Details

I. General information

NPI: 1689201360
Provider Name (Legal Business Name): JACK ANDREW KOTECKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

IV. Provider business mailing address

420 DELAWARE ST SE
MINNEAPOLIS MN
55455-0341
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-5200
  • Fax:
Mailing address:
  • Phone: 612-624-0990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number75814
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: