Basic Information
| Provider Information | |||||||||
| NPI: | 1780621904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK NICOLLET CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 PARK NICOLLET BLVD | ||||||||
| Address2: | ATT BUSINESS SERVICES | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529931835 | ||||||||
| FaxNumber: | 9529931808 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 PARK NICOLLET BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529933123 | ||||||||
| FaxNumber: | 9529932770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | LUHRS | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9528837158 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.