=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245436302
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN P LOES M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3883 COON RAPIDS BLVD NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-2518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-421-2273
-----------------------------------------------------
Fax | 763-421-2236
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14569 WACO ST NW
-----------------------------------------------------
City | RAMSEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55303-6181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-421-7988
-----------------------------------------------------
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 | 30144
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------