1255300984 NPI number — MINNESOTA PAIN CENTER

Table of content: (NPI 1255300984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255300984 NPI number — MINNESOTA PAIN CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA PAIN CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255300984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
574 PRAIRIE CENTER DR
Provider Second Line Business Mailing Address:
#135-310
Provider Business Mailing Address City Name:
EDEN PRAIRIE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55344-7930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-995-0151
Provider Business Mailing Address Fax Number:
651-739-1674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 UNIVERSITY AVE W
Provider Second Line Business Practice Location Address:
SUITE 122
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55103-2072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-731-0707
Provider Business Practice Location Address Fax Number:
651-739-1674
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YUE
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
651-731-0707

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  1345 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 474213200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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