Basic Information
| Provider Information | |||||||||
| NPI: | 1184670044 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHEAST MEDICAL RESEARCH INSTITUTE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHEAST MIDWAY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1390 UNIVERSITY AVE W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551044001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512324800 | ||||||||
| FaxNumber: | 6512324899 | ||||||||
| Practice Location | |||||||||
| Address1: | 1390 UNIVERSITY AVE W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551044001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512324800 | ||||||||
| FaxNumber: | 6512324899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | DAVENPORT | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6512326929 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTHEAST MEDICAL RESEARCH INSTITUTE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 620829100 | 05 | MN | MEDICAID |