Basic Information
| Provider Information | |||||||||
| NPI: | 1063897593 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARK NICOLLET CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARK NICOLLET CLINIC EPISODIC BUNDLE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 PARK NICOLLET BLVD | ||||||||
| Address2: | ATTENTION: BUSINESS SERVICES | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554162527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529931000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3800 PARK NICOLLET BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554162527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529933123 | ||||||||
| FaxNumber: | 9529932770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2015 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | LUHRS | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9528837158 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.