Basic Information
| Provider Information | |||||||||
| NPI: | 1205078300 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC AND YOUNG ADULT MEDICINE, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 7TH ST W | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551162300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512566706 | ||||||||
| FaxNumber: | 6512566766 | ||||||||
| Practice Location | |||||||||
| Address1: | 3470 WASHINGTON DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551221355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512566706 | ||||||||
| FaxNumber: | 6512566766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2009 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | JOSEPH | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6512566706 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 154 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1104806165 | 05 | MN | MEDICAID | 1245210210 | 05 | MN | MEDICAID | 1881057065 | 05 | MN | MEDICAID | 1083694046 | 05 | MN | MEDICAID | 1861558835 | 05 | MN | MEDICAID | 1386991339 | 05 | MN | MEDICAID | 1245210095 | 05 | MN | MEDICAID | 1477870921 | 05 | MN | MEDICAID | 1912987900 | 05 | MN | MEDICAID | 1497735419 | 05 | MN | MEDICAID |