Provider Demographics
NPI:1609682855
Name:STATE OF MINNESOTA - MINNESOTA MANAGEMENT AND BUDGET
Entity type:Organization
Organization Name:STATE OF MINNESOTA - MINNESOTA MANAGEMENT AND BUDGET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDVA HEALTHCARE OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-505-4110
Mailing Address - Street 1:5101 MINNEHAHA AVE BLDG 10
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1647
Mailing Address - Country:US
Mailing Address - Phone:651-396-6260
Mailing Address - Fax:
Practice Address - Street 1:1864 FIRST MINNESOTA
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:MN
Practice Address - Zip Code:55965-2823
Practice Address - Country:US
Practice Address - Phone:651-396-6260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MINNESOTA - MINNESOTA MANAGEMENT AND BUDGET
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice