Basic Information
Provider Information | |||||||||
NPI: | 1295977395 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEDIATRIC AND YOUNG ADULT MEDICINE, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1804 7TH ST W | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551162300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512566706 | ||||||||
FaxNumber: | 6512566710 | ||||||||
Practice Location | |||||||||
Address1: | 1655 BEAM AVE | ||||||||
Address2: | SUITE 108 | ||||||||
City: | MAPLEWOOD | ||||||||
State: | MN | ||||||||
PostalCode: | 551091163 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512566706 | ||||||||
FaxNumber: | 6512566707 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2009 | ||||||||
LastUpdateDate: | 12/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOSEPH | ||||||||
AuthorizedOfficialFirstName: | TERRI | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 6512566706 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 1477870921 | 05 | MN |   | MEDICAID | 1083694046 | 05 | MN |   | MEDICAID | 1245210095 | 05 | MN |   | MEDICAID | 1245210210 | 05 | MN |   | MEDICAID | 1104806165 | 05 | MN |   | MEDICAID | 1861558835 | 05 | MN |   | MEDICAID | 1881057065 | 05 | MN |   | MEDICAID | 1386991339 | 05 | MN |   | MEDICAID | 1497735419 | 05 | MN |   | MEDICAID | 1912987900 | 05 | MN |   | MEDICAID |