Provider Demographics
NPI:1033176797
Name:PHYSICIANS CLINIC OF MINNESOTA
Entity Type:Organization
Organization Name:PHYSICIANS CLINIC OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KNAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-333-5694
Mailing Address - Street 1:3801 BEMIDJI AVE N
Mailing Address - Street 2:STE 6
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4364
Mailing Address - Country:US
Mailing Address - Phone:218-333-5694
Mailing Address - Fax:218-444-4728
Practice Address - Street 1:3801 BEMIDJI AVE N
Practice Address - Street 2:STE 6
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4364
Practice Address - Country:US
Practice Address - Phone:218-333-5694
Practice Address - Fax:218-444-4728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN640127900Medicaid
MNF48894Medicare UPIN
MN640127900Medicaid