Provider Demographics
NPI:1043818354
Name:EDDICTION MEDICINE PLLC
Entity Type:Organization
Organization Name:EDDICTION MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE STAFF
Authorized Official - Prefix:
Authorized Official - First Name:CORI
Authorized Official - Middle Name:
Authorized Official - Last Name:MYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-393-1212
Mailing Address - Street 1:PO BOX 833
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-0833
Mailing Address - Country:US
Mailing Address - Phone:612-393-1212
Mailing Address - Fax:651-257-9422
Practice Address - Street 1:12018 285TH STREET
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045
Practice Address - Country:US
Practice Address - Phone:612-393-1212
Practice Address - Fax:651-400-3892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-09
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1932488608Medicaid