1043556517 NPI number — NOBLE PARKWAY MEDICAL CLINIC PROFESSIONAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043556517 NPI number — NOBLE PARKWAY MEDICAL CLINIC PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOBLE PARKWAY MEDICAL CLINIC PROFESSIONAL CORPORATION
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:
1043556517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4808 85TH AVE NORTH
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
BROOKLYN PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-496-1562
Provider Business Mailing Address Fax Number:
763-657-0581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4808 85TH AVE NORTH
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
BROOKLYN PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-496-1562
Provider Business Practice Location Address Fax Number:
763-657-0581
Provider Enumeration Date:
01/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FAWOLE
Authorized Official First Name:
TAJUDEEN
Authorized Official Middle Name:
O
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
763-496-1562

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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