Provider Demographics
NPI:1386758373
Name:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Entity type:Organization
Organization Name:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER PAYER RELATIONS AND STRATEG
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTZLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-325-2209
Mailing Address - Street 1:200 UNIVERSITY AVE E # 010614
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2507
Mailing Address - Country:US
Mailing Address - Phone:651-325-2209
Mailing Address - Fax:651-325-2221
Practice Address - Street 1:200 UNIVERSITY AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2507
Practice Address - Country:US
Practice Address - Phone:651-726-2890
Practice Address - Fax:651-726-2848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2627133336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025653700Medicaid
MT1386758373Medicaid
SD8535290Medicaid
2049091OtherPK
MN376978000Medicaid
KS100440690BMedicaid
IA1678053FMedicaid
ND21513Medicaid
WI33295600Medicaid
WI33295600Medicaid