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General NPI Number Information
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NPI Number | 1659822146
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Entity Type | Organization
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Legal Business Name | GROUP HEALTH PLAN, INC
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Dates
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Enumeration Date | 10/19/2016
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Last Update Date | 10/19/2016
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Provider Practice Location Address
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Address Line | 2165 WHITE BEAR AVE N
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City | MAPLEWOOD
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State | MN
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Zip | 55109-2707
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Country | US
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Telephone | 952-883-7505
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Fax |
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Provider Business Mailing Address
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Address Line | 2165 WHITE BEAR AVE N
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City | MAPLEWOOD
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State | MN
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Zip | 55109-2707
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SVP, CFO
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Name | DAVID DZIUK
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Credential |
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Telephone | 952-883-6535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | CNP 4768
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License Number State | MN
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