1679791156 NPI number — EAST METRO FAMILY PRACTICE, P.A.

Table of content: (NPI 1679791156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679791156 NPI number — EAST METRO FAMILY PRACTICE, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST METRO FAMILY PRACTICE, P.A.
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:
1679791156
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 SLOAN PL
Provider Second Line Business Mailing Address:
SUITE 35
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55117-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-772-2077
Provider Business Mailing Address Fax Number:
651-772-1889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
234 WENTWORTH AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55118-3525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-455-2940
Provider Business Practice Location Address Fax Number:
651-455-3354
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERRISFORD
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
651-772-1572

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1417 , 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)





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