Basic Information
| Provider Information | |||||||||
| NPI: | 1457444507 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS HEALTH CARE | ||||||||
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| OtherOrganizationName: | CHILDRENS HOSPITALS AND CLINICS OF MINNESOTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 LINCOLN DRIVE, CBC-2-REV/PE | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554361611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529925398 | ||||||||
| FaxNumber: | 9529926917 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 NORTH SMITH AVENUE | ||||||||
| Address2: | CHILDRENS SPECIALTY CLINIC PSYCHOLOGICAL SERVICES STPL | ||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512206720 | ||||||||
| FaxNumber: | 6512206707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | GORELICK | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6128138031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 331019 | MN | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | 331019 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.