Basic Information
| Provider Information | |||||||||
| NPI: | 1457456691 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATALYST MEDICAL CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524427015 | ||||||||
| FaxNumber: | 9524427016 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 LEWIS AVE S STE 201 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553884502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529551963 | ||||||||
| FaxNumber: | 9529551965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 03/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9529551963 | ||||||||
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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 | 261QP2300X | 1540 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 860567000 | 05 | MN | MEDICAID |