=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750655882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICA HEALTH MANAGEMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2012
-----------------------------------------------------
Last Update Date | 11/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 CARLSON PKWY
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-992-2000
-----------------------------------------------------
Fax | 952-992-8665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 CARLSON PKWY
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-992-2000
-----------------------------------------------------
Fax | 952-992-8665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. VICE PRESIDENT GOV. PROGRAMS
-----------------------------------------------------
Name | MR. GLENN ANDIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-992-3977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 21268142
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------