Basic Information
| Provider Information | |||||||||
| NPI: | 1275528671 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MULTICARE ASSOCIATES OF THE TWIN CITIES,PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FRIDLEY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 OSBORNE RD NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637854500 | ||||||||
| FaxNumber: | 7637853314 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 OSBORNE RD NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637854500 | ||||||||
| FaxNumber: | 7637853314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 12/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRANDT | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | MATTHEW | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7637857710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MULTICARE ASSOCIATES OF THE TWIN CITIES, PA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | 35 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 35 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2083X0100X | 35 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 207Q00000X | 35 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.