Provider Demographics
NPI:1114068863
Name:NORTHWIND LUNG SPECIALISTS, P.A.
Entity Type:Organization
Organization Name:NORTHWIND LUNG SPECIALISTS, P.A.
Other - Org Name:NORTHWIND LUNG SPECIALISTS & SLEEP CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:O
Authorized Official - Last Name:GENSMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-746-9463
Mailing Address - Street 1:3758 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2629
Mailing Address - Country:US
Mailing Address - Phone:763-746-9463
Mailing Address - Fax:
Practice Address - Street 1:3758 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2629
Practice Address - Country:US
Practice Address - Phone:763-746-9463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26057207RP1001X, 207RS0012X
MN9955363A00000X
MNR-123245-3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCG0937OtherRAILROAD MEDICARE
MNC02727OtherWPS MEDICARE
MN198292300OtherMEDICAID
MN198292300Medicaid
MNC02727Medicare PIN
MN198292300Medicaid