Allina Health System
Organization Active NPI Family Medicine Physician · Lakeville, MN
NPI 1407546872 · NPPES record last updated Jan 22, 2025
Key facts
- NPI
- 1407546872
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- ALLINA HEALTH SYSTEM
- Practice address
- 17489 Dodd Blvd
Lakeville, MN 55044-4409 - Phone
- (952) 428-1020
- NPI assigned
- May 10, 2023
- Organization subpart
- No
Authorized official
- Name
- Dominica Tallarico
- Title
- Coo
- Phone
- (612) 222-2222
Practitioners 12
-
Grant McFadden, PA-C, MPAS
-
Alexandra Eileen Meekin, PA-C
-
Naomi Autumn Roers, PA-C
-
Brian Howard Roscoe, PSYD LP
-
Shail Sharma, PA-C
-
Kurt Edward Stoll, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 24D2288615 | Allina Health Lakeville North Clinic | Certificate of waiver | Jun 23, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 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 |
|---|---|---|---|---|
| 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 |
| O20231220003623 | MN | DME Supplier - Multi-Specialty - Physician | 4587573613 | Practice locations: Lakeville, MN |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes |
Addresses
Primary practice location
17489 Dodd Blvd
Lakeville, MN 55044-4409
Mailing address
PO Box 43
Mail Route 10585
Minneapolis, MN 55440-0043
Phone (612) 262-1166
Other names
- Allina Health Lakeville North 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 Lakeville, MN
- Align Chiropractic PA
- Allina Health Surgery Center - Lakeville
- Allina Health Surgery Center - Lakeville, LLC
- Allina Health System
- Allina Health System
- Allina Health System
- Allina Health System
- Allina Health System
- Mallory J Allinder
- Kimberly Anne Alschlager
All providers in Lakeville, 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 22, 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.