Basic Information
| Provider Information | |||||||||
| NPI: | 1063801116 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACACIA MEDICAL GROUP PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1993 | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553370995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SUNRISE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT PETER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560825376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5079312200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2015 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | LABRECQUE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7024533799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 50217 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 50217 | 01 | MN | MN LIC 50217 | OTHER |