Provider Demographics
NPI:1144223009
Name:TWIN CITIES DERMATOPATHOLOGY, LLC
Entity Type:Organization
Organization Name:TWIN CITIES DERMATOPATHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-525-0363
Mailing Address - Street 1:9900 13TH AVENUE NORTH
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-5035
Mailing Address - Country:US
Mailing Address - Phone:763-525-0363
Mailing Address - Fax:763-525-0369
Practice Address - Street 1:9900 13TH AVENUE NORTH
Practice Address - Street 2:SUITE 2A
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-5035
Practice Address - Country:US
Practice Address - Phone:763-525-0363
Practice Address - Fax:763-525-0369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1279207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32939100Medicaid
24D0651415OtherCLIA
MN732527400Medicaid
MN732527400Medicaid
MNH300110680Medicare PIN