1225703705 NPI number — MILES MED MANAGEMENT SERVICE CORPORATION

Table of content: (NPI 1225703705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225703705 NPI number — MILES MED MANAGEMENT SERVICE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILES MED MANAGEMENT SERVICE 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:
6
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:
1225703705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4301 ELLIOT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55407-3156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-708-7562
Provider Business Mailing Address Fax Number:
507-738-1963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5775 WAYZATA BLVD STE 767
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-1222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-708-7562
Provider Business Practice Location Address Fax Number:
507-738-1963
Provider Enumeration Date:
08/16/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MILES
Authorized Official First Name:
LISA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
612-708-7562

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1225703705 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1093741886 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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