Allina Health System
Organization Active NPI Family Medicine Physician · Forest Lake, MN
NPI 1447556261 · NPPES record last updated Mar 21, 2024
Key facts
- NPI
- 1447556261
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- ALLINA HEALTH SYSTEM
- Practice address
- 1540 Lake St S
Forest Lake, MN 55025-2628 - Phone
- (651) 464-7100
- Fax
- (651) 241-1515
- NPI assigned
- Jan 27, 2011
- Organization subpart
- No
Authorized official
- Name
- Dominica Tallarico
- Title
- Coo
- Phone
- (612) 222-2222
Practitioners 38
-
Raed H Abdelhadi, MD
-
Maria Batool, M.D
-
Patrick M. Belson, D.O.
-
Bradley Kevin Bloemker, M.D., PH.D.
-
Abigail Brekken, RD, LD
-
Megan Delaney, AGNP
-
Emily Funk, M.D.
-
Laurent Grignon, M.D.
-
Obsa Abdulla Hassan, M.D.
-
Christina Juhl, MD
-
Ronald W. Kaufman, M.D., PH.D.
-
David Krusemark, CRNA
-
Susan C Lemm, NP
-
Kyle Maurer, DO
-
Jill Miller, M.D.
-
Michael P. Murphy, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 24D0398200 | Allina Health Forest Lake Clinic | Certificate of waiver | Sep 21, 2026 |
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 |
| O20120229000829 | MN | DME Supplier - Physician - Unknown Physician Specialty | 4587573613 | Practice locations: Forest Lake, 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
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes | ||
| Clinic/Center | 261Q00000X |
Addresses
Primary practice location
1540 Lake St S
Forest Lake, MN 55025-2628
Mailing address
2925 Chicago Ave
Route 10202
Minneapolis, MN 55407-1321
Phone (612) 262-1166
Other names
- Allina Health Forest Lake 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 Forest Lake, MN
- Ace-DJ Home Care LLC
- Advanced Dermatology Care Medical Cosmetic and Surgery PA
- Sharon Ahlswede
- Brittany Anne Akehurst
- All Family Care Inc
- John Altnow
- Anita Aminoshariae
- Amy Goehner
- Lori J. Anafarta
- Amy Anderson
All providers in Forest Lake, 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 Mar 21, 2024. 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.