=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174311344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RORY GWIN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2025
-----------------------------------------------------
Last Update Date | 06/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 980 RICE ST # NA
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55117-4949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-326-9020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9400 HILLSIDE DR
-----------------------------------------------------
City | CHAMPLIN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55316-2616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 39783
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------