Basic Information
| Provider Information | |||||||||
| NPI: | 1942384193 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITED FAMILY PRACTICE HEALTH CENTER | ||||||||
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| OtherOrganizationName: | UNITED FAMILY PRACTICE HEALTH CENTER SIBLEY MANOR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1026 7TH ST W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551023828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512411000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1307 MAYNARD DR W | ||||||||
| Address2: | SUITE 13 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551162930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516992093 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | NYAKUNDI | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6512411084 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | NA398 | 01 | MN | PREFERRED ONE | OTHER | DB2459 | 01 | MN | RAILROAD MEDICARE | OTHER | 164690 | 01 | MN | UCARE | OTHER | 282M2UN | 01 | MN | BLUE CROSS | OTHER | 697442000 | 05 | MN | MEDICAID |