Basic Information
| Provider Information | |||||||||
| NPI: | 1194259978 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLINA HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | COURAGE KENNY PAIN CLINIC - MINNEAPOLIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | MAIL ROUTE 10202 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122621166 | ||||||||
| FaxNumber: | 6122624258 | ||||||||
| Practice Location | |||||||||
| Address1: | 913 E 26TH ST | ||||||||
| Address2: | STE 503 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554044515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128635100 | ||||||||
| FaxNumber: | 6128635109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2017 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAGNUSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6122621020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.