Provider Demographics
NPI:1700956588
Name:GROUP HEALTH PLAN INC. DBA
Entity type:Organization
Organization Name:GROUP HEALTH PLAN INC. DBA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-726-2654
Mailing Address - Street 1:1736 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HSC 401 PHALEN BOULEVARD
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101
Practice Address - Country:US
Practice Address - Phone:651-254-7875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34275174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F31578Medicare UPIN