Provider Demographics
NPI:1063629798
Name:D PAVELKA REPRODUCTIVE ASSOCIATES, PA
Entity Type:Organization
Organization Name:D PAVELKA REPRODUCTIVE ASSOCIATES, PA
Other - Org Name:PAVELKA REPRODUCTIVE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-783-8155
Mailing Address - Street 1:500 OSBORNE RD NE STE 260
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2768
Mailing Address - Country:US
Mailing Address - Phone:763-783-8155
Mailing Address - Fax:763-783-1373
Practice Address - Street 1:500 OSBORNE RD NE STE 260
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2768
Practice Address - Country:US
Practice Address - Phone:763-783-8155
Practice Address - Fax:763-783-1373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27008261QA0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95441Medicare UPIN