Basic Information
| Provider Information | |||||||||
| NPI: | 1639211410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHANT | ||||||||
| FirstName: | BHAIRAVI | ||||||||
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| OtherLastName: | MAHANT | ||||||||
| OtherFirstName: | RAVI | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8192 GALWAY RD | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517398108 | ||||||||
| FaxNumber: | 6512540910 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 PHALEN BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551305302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512543200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4816 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.