Basic Information
| Provider Information | |||||||||
| NPI: | 1730297987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMBERG | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1690 UNIVERSITY AVE W | ||||||||
| Address2: | STE 570 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551043741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512324800 | ||||||||
| FaxNumber: | 6512324899 | ||||||||
| Practice Location | |||||||||
| Address1: | 1690 UNIVERSITY AVE W | ||||||||
| Address2: | STE 570 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551043741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512324800 | ||||||||
| FaxNumber: | 6512324899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 30394 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30746400 | 05 | WI | MEDICAID | 803582200 | 05 | MN | MEDICAID |