Provider Demographics
NPI:1730586819
Name:UNIVERSITY OF MINNESOTA PHYSICIANS
Entity type:Organization
Organization Name:UNIVERSITY OF MINNESOTA PHYSICIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:612-884-0802
Mailing Address - Street 1:6300 SHINGLE CREEK PARKWAY
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2127
Mailing Address - Country:US
Mailing Address - Phone:763-782-6400
Mailing Address - Fax:763-782-9558
Practice Address - Street 1:814 SOUTH 3RD ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415
Practice Address - Country:US
Practice Address - Phone:612-888-9792
Practice Address - Fax:612-888-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02390OtherMEDICARE PTAN