Provider Demographics
NPI:1164569679
Name:UNIVERSITY OF MINNESOTA PHYSICIANS
Entity Type:Organization
Organization Name:UNIVERSITY OF MINNESOTA PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-884-0802
Mailing Address - Street 1:6300 SHINGLE CREEK PKWY
Mailing Address - Street 2:STE 600
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2124
Mailing Address - Country:US
Mailing Address - Phone:763-782-6400
Mailing Address - Fax:763-782-9558
Practice Address - Street 1:1300 2ND STREET SOUTH STE 180
Practice Address - Street 2:CENTER FOR SEXUAL HEALTH
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454
Practice Address - Country:US
Practice Address - Phone:612-625-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN701372800Medicaid
MN701372800Medicaid