Basic Information
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| NPI: | 1053344788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST PAUL RHEUMATOLOGY P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2854 HIGHWAY 55 | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551212156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516444277 | ||||||||
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| Address1: | 2854 HIGHWAY 55 | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551212156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516444277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | RIDLEY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6516444277 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 569199100 | 05 | MN | MEDICAID |