Allina Health System
Organization Active NPI Family Medicine Physician · St Paul, MN
NPI 1023314804 · NPPES record last updated Jan 14, 2025
Key facts
- NPI
- 1023314804
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- ALLINA HEALTH SYSTEM
- Practice address
- 1021 Bandana Blvd E
Ste 100
St Paul, MN 55108-5109 - Phone
- (651) 241-9700
- NPI assigned
- Jan 27, 2011
- Organization subpart
- No
Authorized official
- Name
- Dominica Tallarico
- Title
- Coo
- Phone
- (612) 222-2222
Practitioners 49
-
Jessica J Dehler, PA-C
-
Abdulrazak Esse, MD
-
Mara Joan Fritz, NP
-
Adam J Goble, ARNP
-
Ellen Hanson, CNP
-
Jimmy Huynh, MD, PHD
-
Thomas Jerry Ibach, M.D.
-
Halley Elizabeth Jones, PA-C
-
Jason Lloyd Keszler, D.O.
-
Brent James King, MD
-
David F Labadie, MD
-
Lucie Larson, MD
-
Indra A Lim, MD
-
David Lin, M.D.
-
Suzanne Moffit, D.O.
-
Sharilyn K Moore, DPM
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 24D0399281 | Allina Health Bandana Square Clinic | Accreditation | Dec 22, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in MN
All facility ownership & control disclosures 3
| Facility | Type | Role | Since |
|---|---|---|---|
| St Francis Regional Medical Center |
Hospital | 5% Or Greater Direct Ownership Interest (47.5%) | Nov 15, 2007 |
| Courage Kenny Rehabilitation Institute TRP |
Skilled nursing facility | 5% Or Greater Direct Ownership Interest (100%) Operational/Managerial Control |
Jun 1, 2013 Jun 1, 2013 |
| Allina Health Restorative Suites |
Skilled nursing facility | 5% Or Greater Direct Ownership Interest (100%) | Nov 10, 2022 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040319000460 | MN | Part B Supplier - Clinic/Group Practice | 4587573613 |
Receives reassigned benefits from 4,246 practitioners This NPI is an additional NPI on the enrollment |
| O20111216000537 | MN | DME Supplier - Physician - Unknown Physician Specialty |
4587573613 | Practice locations: St Paul, MN |
| O20221213001713 | MN | Part B Supplier - Clinic/Group Practice | 4587573613 |
Receives reassigned benefits from 3,000 practitioners This NPI is an additional NPI on the enrollment |
National Provider Directory
Locations
11269 Jefferson Hwy N
Champlin, MN 55316
Phone (763) 236-0600
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes | ||
| Sleep Medicine (Family Medicine) Physician |
207QS1201X | |||
| Sleep Disorder Diagnostic Clinic/Center | 261QS1200X | |||
| Durable Medical Equipment & Medical Supplies | 332B00000X |
Addresses
Primary practice location
1021 Bandana Blvd E
Ste 100
St Paul, MN 55108-5109
Mailing address
PO Box 43
Mail Route 10585
Minneapolis, MN 55440-0043
Phone (612) 262-1166
Other practice location 1
1010 Bandana Blvd E
Ste 236
St Paul, MN 55108-5107
Phone (651) 641-7100
Other names
- Allina Health Bandana Square Clinic
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://esmd.cioxhealth.com:8291/Gateway/DocumentSubmission/1_1/NhinService/XDRRequest_Service | Other | Ciox Health |
Other providers in St Paul, MN
- Allied Homes Limited Liability Company
- Allied Operation Support LLC
- Allied Physical Therapy LLC
- Allied Support LLC
- Allina Health System
- Allina Health System
- Allina Health System
- Allina Health System
- Allina Health System
- Allina Health System
All providers in St Paul, MN · Family Medicine Physician in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 14, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.