Basic Information
| Provider Information | |||||||||
| NPI: | 1790772259 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY FAMILY HEALTH CLINIC, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4570 CTY HWY 61 | ||||||||
| Address2: | |||||||||
| City: | MOOSE LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557679401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184854491 | ||||||||
| FaxNumber: | 2184854724 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 LUNDORFF DR | ||||||||
| Address2: | |||||||||
| City: | SANDSTONE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550725051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202452250 | ||||||||
| FaxNumber: | 3202452555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 10/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | NIELSEN | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2184854491 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R 137363-9 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | 43634 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 43633 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 43634 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | 11706 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | R 120278-4 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | R 147424-0 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | 41745 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 47303 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 34715 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 46671 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 49738 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 54207 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 43633 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | 48729 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.