Basic Information
| Provider Information | |||||||||
| NPI: | 1578830733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S CLINIC NETWORK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | METROPOLITAN PEDIATRIC SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 LINCOLN DRIVE | ||||||||
| Address2: | CBC-2-REV/PE | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554361611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529925691 | ||||||||
| FaxNumber: | 9529926917 | ||||||||
| Practice Location | |||||||||
| Address1: | 6517 DREW AVENUE SOUTH | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529209191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | BRENDA LU | ||||||||
| AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP AND CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6128136129 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.