Basic Information
| Provider Information | |||||||||
| NPI: | 1639274160 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA PARK MEDICAL GROUP, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CPMG-ANDOVER PARK CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6401 UNIVERSITY AVE NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554324341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7635713008 | ||||||||
| Practice Location | |||||||||
| Address1: | 13819 HANSON BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553047608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7638624415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONDON | ||||||||
| AuthorizedOfficialFirstName: | JOEN | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7635865839 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLUMBIA PARK MEDICAL GROUP, PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 02071BR | 01 | MN | BCBS | OTHER | CT1003 | 01 | MN | MEDICARE RAILROAD | OTHER | UC0003 | 01 | MN | UCARE URGENT CARE | OTHER | 54814 | 01 | MN | HEALTHPARTNERS | OTHER | 122190 | 01 | MN | UCARE MN | OTHER | 98-66092 | 01 | MN | MEDICA URGENT CARE | OTHER | 98-00470 | 01 | MN | MEDICA NUMBER | OTHER |