Provider Demographics
NPI:1386969103
Name:NORTH SUBURBAN UROLOGY OF COON RAPIDS, INC.
Entity type:Organization
Organization Name:NORTH SUBURBAN UROLOGY OF COON RAPIDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAIKEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-427-3668
Mailing Address - Street 1:3879 COON RAPIDS BLVD
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433
Mailing Address - Country:US
Mailing Address - Phone:763-427-3668
Mailing Address - Fax:763-427-5029
Practice Address - Street 1:3879 COON RAPIDS BLVD
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-427-3668
Practice Address - Fax:763-427-5029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29898208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN482780500Medicaid
MN482780500Medicaid
340000188Medicare PIN