Provider Demographics
NPI:1104850155
Name:MINNESOTA HEAD AND NECK PAIN CLINIC, PA
Entity Type:Organization
Organization Name:MINNESOTA HEAD AND NECK PAIN CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARDOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-332-7470
Mailing Address - Street 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:STE 189S
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114
Mailing Address - Country:US
Mailing Address - Phone:651-332-7474
Mailing Address - Fax:651-332-7475
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:STE 189S
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114
Practice Address - Country:US
Practice Address - Phone:651-332-7474
Practice Address - Fax:651-332-7475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN11668MIOtherBLUE CROSS
MN11668MIOtherBLUE CROSS
MNC00801Medicare UPIN