Provider Demographics
NPI:1114019858
Name:REGENTS OF THE UNIVERSITY OF MINNESOTA
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF MINNESOTA
Other - Org Name:COMMUNITY-UNIVERSITY HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD-DIOUF
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:612-301-0698
Mailing Address - Street 1:2001 BLOOMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3074
Mailing Address - Country:US
Mailing Address - Phone:612-301-3433
Mailing Address - Fax:612-627-4205
Practice Address - Street 1:2001 BLOOMINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3074
Practice Address - Country:US
Practice Address - Phone:612-301-3433
Practice Address - Fax:612-627-4205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF MINNESOTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-29
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN855553200261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN855553200Medicaid
MN241820Medicare ID - Type Unspecified