1649370396 NPI number — COLUMBIA PARK MEDICAL GROUP, PA

Table of content: (NPI 1649370396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649370396 NPI number — COLUMBIA PARK MEDICAL GROUP, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBIA PARK MEDICAL GROUP, PA
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:
1649370396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6401 UNIVERSITY AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRIDLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55432-4341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-572-5710
Provider Business Mailing Address Fax Number:
763-571-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10000 ZANE AVE N
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BROOKLYN PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55443-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-569-6281
Provider Business Practice Location Address Fax Number:
763-569-6211
Provider Enumeration Date:
09/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEIR
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
LOUIS
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
763-586-5877

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  262454-9 , 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: 10118513 . This is a "IPC NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 076751 . This is a "ANDA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 831146 . This is a "MCKESSON" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2426220 . This is a "NABP NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 02071BR . This is a "BCBS DME NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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