Basic Information
| Provider Information | |||||||||
| NPI: | 1932150117 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBIA PARK MEDICAL GROUP, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6401 UNIVERSITY AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554324341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7635713008 | ||||||||
| Practice Location | |||||||||
| Address1: | 6401 UNIVERSITY AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554324341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7635713008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | CONDON | ||||||||
| AuthorizedOfficialFirstName: | JOEN | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7635865839 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207K00000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207R00000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RI0200X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207V00000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207W00000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207X00000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Y00000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208000000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2083X0100X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 208600000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208M00000X | 147 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 147 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 147 | 01 | MN | STATE PROF. REGISTRATION | OTHER | 1014268 | 01 | MN | PREF ONE URGENT CARE # | OTHER | AQ9091045486 | 01 | MN | PREFERRED ONE | OTHER | 02071BR | 01 | MN | BCBS OF MN | OTHER |