Provider Demographics
NPI:1164477709
Name:MINNESOTA CENTER FOR OBESITY, METABOLISM & ENDOCRINOLOGY, PA
Entity Type:Organization
Organization Name:MINNESOTA CENTER FOR OBESITY, METABOLISM & ENDOCRINOLOGY, PA
Other - Org Name:MNCOME, PA
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ-CAMPOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-379-1600
Mailing Address - Street 1:1185 TOWN CENTRE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1187
Mailing Address - Country:US
Mailing Address - Phone:651-379-1600
Mailing Address - Fax:651-379-1650
Practice Address - Street 1:1185 TOWN CENTRE DR
Practice Address - Street 2:SUITE 220
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1187
Practice Address - Country:US
Practice Address - Phone:651-379-1600
Practice Address - Fax:651-379-1650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1591207Q00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNDB4333OtherRR MEDICARE
MN410654700Medicaid
MN96386OtherHEALTHPARTNERS
MN165867H314OtherUCARE
MN547S0MIOtherBLUE CROSS BLUE SHIELD
MNC03334OtherMEDICARE PTAN
MN547S0MIOtherBLUE CROSS BLUE SHIELD