Provider Demographics
NPI:1164400495
Name:VINE, CRAIG JON (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:JON
Last Name:VINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVENUE WEST
Mailing Address - Street 2:SUITE 229N
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114
Mailing Address - Country:US
Mailing Address - Phone:651-645-3115
Mailing Address - Fax:651-645-2752
Practice Address - Street 1:2550 UNIVERSITY AVENUE WEST
Practice Address - Street 2:SUITE 229N
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114
Practice Address - Country:US
Practice Address - Phone:651-645-3115
Practice Address - Fax:651-645-2752
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2013-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN337122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN317T6VIOtherBCBS OF MN
MN1530494OtherMEDICA
MN786505800Medicaid
MN260002134Medicare ID - Type Unspecified
MN1530494OtherMEDICA