1629474531 NPI number — MIDWEST INJURY PHYSICIANS, LLC

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 1629474531 NPI number — MIDWEST INJURY PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST INJURY PHYSICIANS, LLC
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:
1629474531
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7373 FRANCE AVE S STE 606
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-4552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-207-7463
Provider Business Mailing Address Fax Number:
952-831-0276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 W LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55408-4898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-584-2168
Provider Business Practice Location Address Fax Number:
612-886-1578
Provider Enumeration Date:
11/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
THORSON
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER/MEDICAL DIRECTOR
Authorized Official Telephone Number:
612-207-7463

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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