NPIMap

Organization Active NPI

Allina Health System

Doing business as Allina Health Forest Lake Clinic

  • Family Medicine Physician
  • Forest Lake, MN
National Provider Identifier
1447556261
Registry record updated Mar 21, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
ALLINA HEALTH SYSTEM
Doing business as
Allina Health Forest Lake Clinic
Practice address
1540 Lake St S
Forest Lake, MN 55025-2628
Phone
(651) 464-7100
Fax
(651) 241-1515
NPI assigned
Jan 27, 2011
Last updated
Mar 21, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 21, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dominica Tallarico
Title
Coo
Phone
(612) 222-2222

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary
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 1

  • Allina Health Forest Lake Clinic Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://esmd.cioxhealth.com:8291/Gateway/DocumentSubmission/1_1/NhinService/XDRRequest_Service Other Ciox Health

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D0398200Allina Health Forest Lake Clinic1540 South Lake Street, Forest Lake, MN 55025Certificate of waiverSep 21, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
St Francis Regional Medical CenterShakopee, MN, CCN 240104 Hospital 5% Or Greater Direct Ownership Interest (47.5%) Nov 15, 2007
Courage Kenny Rehabilitation Institute TRPGolden Valley, MN, CCN 245519 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Jun 1, 2013
Jun 1, 2013
Allina Health Restorative SuitesPlymouth, MN, CCN 245624 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%) Nov 10, 2022

Practitioners & affiliated clinicians

Practitioners 38

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 38

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1296086400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710979200000",
    "number": "1447556261",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2925 CHICAGO AVE",
            "address_2": "ROUTE 10202",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554071321",
            "telephone_number": "612-262-1166"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1540 LAKE ST S",
            "city": "FOREST LAKE",
            "state": "MN",
            "postal_code": "550252628",
            "telephone_number": "651-464-7100",
            "fax_number": "651-241-1515"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ALLINA HEALTH SYSTEM",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-01-27",
        "last_updated": "2024-03-21",
        "certification_date": "2024-03-21",
        "status": "A",
        "authorized_official_last_name": "TALLARICO",
        "authorized_official_first_name": "DOMINICA",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "612-222-2222"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.cioxhealth.com:8291/Gateway/DocumentSubmission/1_1/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "esmd.cioxhealth.com and OID is '2.16.840.1.113883.3.6635.1.1",
            "affiliationName": "Ciox Health",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "925 N Point Pkwy",
            "city": "Alpharetta",
            "state": "GA",
            "country_code": "US",
            "postal_code": "300055210",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Allina Health Forest Lake Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Allina Health Forest Lake Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Forest Lake, MN

Sources for this page

Verify at the official NPI Registry.