Basic Information
| Provider Information | |||||||||
| NPI: | 1356585442 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINNESOTA ONCOLOGY HEMATOLOGY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 OSBORNE RD NE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637861620 | ||||||||
| FaxNumber: | 7637803099 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 OSBORNE RD NE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637861620 | ||||||||
| FaxNumber: | 7637803099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2009 | ||||||||
| LastUpdateDate: | 10/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | FLYNN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6128638585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207VX0201X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 363L00000X | 1076 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RH0003X | 1076 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | C01828 | 01 | MN | MEDICARE ID | OTHER |