Provider Demographics
NPI:1447352836
Name:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Entity type:Organization
Organization Name:GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-312-3105
Mailing Address - Street 1:200 UNIVERSITY AVE E
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:651-291-2848
Mailing Address - Fax:651-325-2174
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:651-291-2848
Practice Address - Fax:651-325-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X, 282NC2000X, 284300000X
MN273Y00000X, 332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No273Y00000XHospital UnitsRehabilitation Unit
No284300000XHospitalsSpecial Hospital
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0520726Medicaid
MN1111HGIOtherBLUE CROSS BLUE SHIELD
2427462OtherPHARMACY-NCPDP
MN996047300Medicaid
WI11003700Medicaid
MT0418080Medicaid
MN243300Medicare Oscar/Certification
MN243300Medicare Oscar/Certification