NPIMap

Individual provider Active NPI

Philip Bruce Imholte, M.D.

  • Family Medicine Physician
  • Grand Rapids, MN
National Provider Identifier
1760604623
Registry record updated Oct 21, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
49754 Issued in MN
Practice address
1601 Golf Course Road
Grand Rapids, MN 55744
Phone
(218) 326-5000
Fax
(218) 999-1380
NPI assigned
May 2, 2007
Last updated
Oct 21, 2010By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 21, 2010

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 49754 MN Primary

Addresses

Primary practice location

1601 Golf Course Road
Grand Rapids, MN 55744

Mailing address

1601 Golf Course Road
Grand Rapids, MN 55744
Phone (218) 326-5000

Other identifiers 4

IdentifierTypeStateIssuer
17P85IMOtherMNBCBS
244940000MedicaidMN
P00438363OtherRR MEDICARE PTAN
1760604623OtherMEDICA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20070911000804 MN Practitioner - Family Practice 0244323913 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2006
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Grand Itasca Clinic and HospitalGroup PAC ID 8123939550, 328 clinicians

Practice addresses (Care Compare)

111 SE 3Rd St
Grand Rapids, MN 55744-3663
Phone (218) 326-3401

1601 Golf Course Rd
Grand Rapids, MN 55744-8648
Phone (218) 326-3401

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
92.35 of 100Reported as group
Quality
88.69
Promoting interoperability
100
Improvement activities
40
Cost
76.65

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
49754MNMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Grand Itasca Clinic and Hospital CurrentSince Nov 24, 2009 Accepting new patients
Grand Itasca Clinic and Hospital CurrentSince Nov 24, 2009 Accepting new patients
The Duluth Clinic, LTD. Past Accepting new patients

Locations

111 SE 3rd St
Grand Rapids, MN 55744
Phone (218) 326-3401

126 SE 1st Ave
Grand Rapids, MN 55744
Phone (218) 326-3401

1601 Golf Course Rd
Grand Rapids, MN 55744
Phone (218) 326-3401

Interoperability endpoints

  • Direct secure messaging: pimholte414308@fairview.direct-ci.com

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1178064000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1287619200000",
    "number": "1760604623",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1601 GOLF COURSE ROAD",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "55744",
            "telephone_number": "218-326-5000",
            "fax_number": "218-999-1380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1601 GOLF COURSE ROAD",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "55744",
            "telephone_number": "218-326-5000",
            "fax_number": "218-999-1380"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IMHOLTE",
        "first_name": "PHILIP",
        "middle_name": "BRUCE",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-05-02",
        "last_updated": "2010-10-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "49754",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "17P85IM",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "244940000",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE PTAN",
            "identifier": "P00438363",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA",
            "identifier": "1760604623",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MN

Sources for this page

Verify at the official NPI Registry.