Provider Demographics
NPI:1104505015
Name:REGENTS OF THE UNIVERSITY OF MINNESOTA
Entity type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-626-4232
Mailing Address - Street 1:515 DELAWARE ST SE
Mailing Address - Street 2:7-521 MOOS TOWER
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0357
Mailing Address - Country:US
Mailing Address - Phone:612-625-4777
Mailing Address - Fax:
Practice Address - Street 1:515 DELAWARE ST SE FL 6
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0357
Practice Address - Country:US
Practice Address - Phone:612-625-4777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF MINNESOTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental