=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144368531
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF MINNESOTA PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5775 WAYZATA BLVD STE 255
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-1275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 122-738-7106
-----------------------------------------------------
Fax | 612-273-8727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 860217
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55486-0217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-782-6400
-----------------------------------------------------
Fax | 763-782-9558
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | WILLIAM SIBERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-884-0600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------