Basic Information
Provider Information | |||||||||
NPI: | 1124274527 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MILL CITY CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6300 SHINGLE CREEK PKWY | ||||||||
Address2: | SUITE 600 | ||||||||
City: | BROOKLYN CENTER | ||||||||
State: | MN | ||||||||
PostalCode: | 554302124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7637826400 | ||||||||
FaxNumber: | 7637829558 | ||||||||
Practice Location | |||||||||
Address1: | 901 SECOND ST S | ||||||||
Address2: | SUITE A | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 55415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6122736089 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2008 | ||||||||
LastUpdateDate: | 02/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONNSON | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 6128840802 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   | MN | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QP2300X |   | MN | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.