Provider Demographics
NPI:1114313798
Name:REHABILITATION MEDICINE PHYSICIANS LLC
Entity Type:Organization
Organization Name:REHABILITATION MEDICINE PHYSICIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:984-377-3422
Mailing Address - Street 1:631 CLEVELAND AVE S STE 5
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1244
Mailing Address - Country:US
Mailing Address - Phone:612-516-5558
Mailing Address - Fax:845-698-6174
Practice Address - Street 1:8400 NORMANDALE LAKE BLVD
Practice Address - Street 2:STE 920
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-1085
Practice Address - Country:US
Practice Address - Phone:984-377-3422
Practice Address - Fax:845-698-6174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-10
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57253208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1114313798Medicaid
3060128Medicare PIN