Basic Information
| Provider Information | |||||||||
| NPI: | 1922586270 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MBH-MN MEDICAL CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN ST # 190 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551123271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124542046 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 MAIN ST STE 260 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551123273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267558 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2018 | ||||||||
| LastUpdateDate: | 08/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | LILE | ||||||||
| AuthorizedOfficialFirstName: | BUD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6122327558 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.